Transcription
I'm going to be honest: I'm terrified right now. Because whenever I find myself in this kind of chair, I just know my bank account is in danger. And it makes no sense to me.
A few months ago, I had my sixth open heart surgery. I didn't pay much of anything. Nine hours on the operating table, 10 days in the hospital, round-the-clock care, and hardly a dent in my wallet. And yes, that's because I have good health insurance. But I've got dental insurance, too, and from the same employer. Yet for three or four hours in a chair like this over the past eight months, I'm looking at $8,000 out of pocket. All for work on two teeth. Work on three heart valves? $0. Dental care is vital and dentists should make a good living, but the difference in what I've had to pay for oral and medical care is just mind-boggling. And I'm not alone. Going to the dentist is a luxury. I don't understand why every single time you go to the dentist, it's $1 million. How do people pay this?
So how did dental care get so expensive? And why does dental insurance cover so little? I drilled down to the root of the problem and figured out the two major reasons why the finances of dental care suck for us and for dentists themselves.
[Dr. Anh-Thu Dang] My first job out of dental school was with Heartland Dental. It was a very challenging environment to start as a new grad.
[Jordan] Dr. Anh-Thu Dang has been practicing dentistry for nine years. She started at a corporate dental office operated by what's known as a dental support organization, or DSO. And DSOs play a growing role in the skyrocketing costs of dental work and plummeting quality of care.
[Dr. Dang] I signed with them when I was still in school, and I was promised a lot of things, and that wasn't always the case.
[Jordan] The broad pitch is that the corporation— this DSO—does all the back-end work: the administration, the finances, so dentists can just focus on patients.
[Dr. Jill Tanzi] They're not just managing, even though that's what they're claiming to do, is just manage the finances.
[Jordan] Dr. Jill Tanzi also worked for a DSO right out of dental school.
[Dr. Tanzi] It's really not as separate as you would think. It's still—they're getting their tentacles into the whole practice.
[Dr. Dang] They would push a lot of overtreatment. We would have management, so people who are not clinical, who do not have dental degrees, they would push for a more expensive procedure even when I would see as a clinician it was not clinically indicated.
[Jordan] Heartland Dental, where Dr. Dang worked, is the biggest dental chain in the country. It's majority owned by KKR, the infamous private equity firm, and operates around 1,800 offices nationwide.
[Dr. Dang] Every morning we would receive in our internal emails a spreadsheet that would rank doctors by their daily production from the highest-producing to the lowest-producing doctor. If you miss your monthly goals, usually you get a meeting with the regional manager. They'll visit the office and say, hey, your numbers are down. You need to aim for X amount of crowns a month. So we would be told, you know, by management with no, you know, clinical degree that, you know, we need to cut the slack and diagnose more, basically.
Dr. Dang was just one of the many dentists and hygienists I spoke to who alleged experiencing this extreme pressure at DSOs. I think the public knows the game is rigged. I just don't think they know how bad it's rigged.
[Jordan] Dr. Michael Davis is a long time dentist in New Mexico. He’s seen up close the problems that can proliferate when corporations get involved in running a dentist's office. The public needs to know the term DSO. They determine hours of operations, what labs to use, what materials to use.
[Dr. Dang] Looks pretty good. You know, this lab does great work. You know, it's not like working at another corporate office where, you know, you have to choose from a list of approved dental labs. This one's local. It's not sent overseas.
[Dr. Davis] They may use discount laboratories, whereas the crowns are offshored to China. We found lead in some of these materials— E.coli bacteria, fecal bacteria on some of these dental crowns.
[DSOs] determine many, many items which only a doctor should make. And they're making those decisions. And there's no real enforcement against that. But the thing is, there really should be.
[Emma Freer] Basically, since the the 19th century, there's been a lot of state laws that are intended to prohibit the corporate practice of medicine.
[Jordan] Emma Freer is a senior policy analyst for health care with the American Economic Liberties Project, where she's been tracking corporate consolidation in health care.
[Freer] So a lot of these laws will require that a physician practice is owned by a licensed physician. But there are a lot of loopholes to these laws. And they also vary state to state.
[Jordan] And this is how DSOs get around these sorts of laws: there is a dentist owner—on paper. The term ownership, they've twisted that to the point where it has virtually no meaning. They install what we call nominal owners or minority owners, and they call that the practice owner. And yet they have minimal to no control. Control rests within corporate management, not the doctor.
[Jordan] And that is the model for what private equity-owned companies like Heartland Dental and Aspen Dental, the two largest DSOs, are doing around the country.
[Freer] There's a lot of concerns about private equity involvement in health care, because those firms really have a conflict of interest. Their goal isn't necessarily providing quality dental care and, you know, safe working conditions for a dentist. It’s to make high returns for their investors. There are a lot of great dentists and hygienists at DSOs, including Heartland and Aspen Dental. But there are also a lot of brutal headlines, in particular at Aspen Dental...
[Anchor] ...uncovering the alleged horrible experiences of Aspen Dental customers. A Richmond, Missouri, woman went to the dentist for one broken tooth and ended up having all her teeth pulled. Aspen dental was accused of being deceptive in an effort to get people to sign up for their services.
[Jordan] ...and rough online reviews. There are also years of lawsuits against prominent DSOs with millions upon millions of dollars in settlements. That includes back in 2015, when Aspen settled a lawsuit with the state of New York, which alleged that corporate pressure impacted patients’ care and dentist decisions.
[Dr. Davis] Is their doctor truly acting in their best interests? We'd like to assume they are. But if they're working for a third party without disclosures, that's deceitful. That really goes against the grain of what we should be doing in health care.
[Jordan] And the thing is, the way this is all set up, you might not even know this is happening to you or your dentist. A lot of practices are being bought and they call it an invisible DSO.
[Dr. Dang] You won't see an office named Heartland Dental. You'll see an office named Smith Family Dental or Tacoma Family Dental, and it looks like a private office. With patients, they would be very surprised to know that we were managed by a huge, you know, billion dollar company. So this DSO model, this corporate capture of dentistry, turning health care into a profit pump, that's one part of the problem. The other? Dental insurance, if you could even call it that. Dental insurance is not insurance. It's just like a discount coupon for the patient. And every dentist I talked to said basically the same thing. I don't think dental insurance is a good value for the dollar. It's not really insurance. And it's frustrating because patients don't know how it works and how different it is from medical insurance.
[Jordan] The idea behind medical insurance is straightforward. You pay monthly premiums to an insurance company, and if you get sick, the insurance company covers the cost of your care. Patient goes to the doctor, doctor bills the insurance company, and the insurance pays the doctor a fair, pre-negotiated fee. It doesn't always work out like that obviously, but that’s the model. But that's not how dental insurance works or was ever meant to operate. Dental insurance has never, ever covered catastrophic. And that's what medical insurance truly is designed to do. Dental insurance has never done that. Ever. Dental insurance was devised decades after Americans started using health insurance. And because dental work was considered cosmetic, it just never developed or got regulated in the same way. Instead, dental insurance is basically like a coupon, like Dr. Tanzi said. You still pay monthly premiums to an insurance company, but that company only covers a little bit of the care, setting annual maximums that haven't increased much in half a century.
[Dr. Davis] So if you're cap is $1,500 or $2,000 per year, that's it. And then it starts again the next year. If there's a catastrophic situation— patient needs multiple crowns, needs implants, needs some fairly extensive rehabilitative dentistry— it's not gonna cover it. I have an appointment later this month that will eat up my entire annual maximum, then cost me an extra $1,600 all in one day, all for one tooth.
[Dr. Dang] Over the years, the dental insurance company has been trying ways to maximize their profit by covering less. And it's easy for them to do because there's not much competition.
[Freer] There's one dominant dental insurer in the U.S. called Delta Dental, and in many of the markets that Delta Dental operates, they have, you know, 50 or 60% market share. They're really the most dominant dental insurer. And in some states they have much higher market share. It gives Delta Dental a lot of negotiating leverage in dictating reimbursement rates. And so that puts dentists at a huge disadvantage.
[Jordan] That's exactly how Dr. Tanzi felt when she realized she was actually losing money by being in-network with Delta Dental.
[Dr. Tanzi] I had patients coming in for cleanings. We were losing $11 a patient on a regular dental cleaning. So you have to make it up somewhere else. I think that's wrong, and I don't think it's ethical. And I thought I just, you know, I had to get out.
There have been plenty of lawsuits against insurance companies like Delta Dental over the years, like this antitrust lawsuit from 2019, and this one from 2024, and most recently, one filed on New Year's Eve against Delta Dental, alleging that the company misrepresents its out-of-network coverage, which winds up costing patients even more money. By the way, the CEO of Delta Dental made $7 million in 2023. Not bad for running a nonprofit.
So we’ve got corporate dentistry and massive not-so-nonprofit insurance companies combining to drive up the cost of dental care. Just imagine if the two came together. Well, they just did. Delta Dental just bought Cherry Tree Dental, a midsized DSO in the Midwest.
[Freer] And that creates a lot of conflicts of interest. Delta Dental, by owning a dental practice, is making money kind of at multiple points along the transaction. They're accepting premium payments. They are taking the profits from the dental practice, they’re incentivized to change prices and reimbursement rates. They're incentivized to steer their insurance customers to their affiliated providers and away from competitors. It's less choice and it's fewer independent dental practices. Back in 1999, 65% of American dentists were in solo practice. By 2023, it was just 35%. And DSOs are a large part of that decline. Between 2013 and 2024, the number of dentists who work for these big chains jumped from 7% to 16%.
[Dr. Tanzi] Some people don't want to be seen in a corporate situation. They want to know that the dentist that owns the practice has an interest in them, an interest in everything that goes on in that practice, not somebody sitting in New York in private equity headquarters.
There have been some attempts to rein in the power of corporations in dental offices, like stronger bans on corporate practice of medicine in Colorado and Oregon. And in Massachusetts, there's a new law requiring dental insurance companies to spend 83% of their premium intake on actual health care, putting dental insurance in line with what health insurance companies have to pay. Dr. Tanzi helped lead the way on the passage of the Massachusetts law.
[Dr. Tanzi] I think it could go higher. I mean, I don't think it needs to be 83. It could be 90. They take in a ton of money, and with computers and AI and everything now, like, they should be able to be more efficient. They've wanted us to be more efficient for years and jam patients into our schedule. But like, maybe it's time for insurance companies to be more efficient.
In addition to Massachusetts, Nevada, North Dakota and New Mexico have all set required minimum spends for insurers. Other states like California, Virginia and Maine now require that insurance companies report their spending on care. It's the first step toward establishing minimums there, too. But these regulations won't solve everything. Outside of a Medicare for All system that fairly compensates dentists, we're looking at a number of partial fixes. The battle over corporate ownership of medical practices has been raging across the U.S. And now a growing number of states are restricting private equity’s involvement in medicine. California just prohibited private investors from interfering with the judgment of actual medical professionals, while Oregon just placed even more stringent restrictions on DSO involvement in practices.
As for me, my cardiac surgeon told me that the best thing I can do for my heart is to go for regular dental checkups. I have to be mindful of endocarditis, an infection in the heart that usually starts with oral health. And thanks to a system that considers medical and dental care two totally separate things, those trips to the dentist will cost me more than any hospitalization.