[00:00:00] Welcome to Think Oral, where we connect the unconnected between oral and physical health.

[00:00:11] I'm your host, Dr. Jonathan Levine.

[00:00:13] And I'm your host, Maria Filipova.

[00:00:15] Let's get at it.

[00:00:16] Dr. Levine, how are you today?

[00:00:26] I'm great, Maria.

[00:00:27] Great to see you.

[00:00:28] It's been a little while, right?

[00:00:29] It's been a while.

[00:00:30] I'm very excited because today we have a guest who not only knows the numbers, he is self-proclaimed

[00:00:38] data wonk and a nerd and an economist, a PhD, who has the creativity to envision a different

[00:00:47] world and the courage to go after it.

[00:00:49] And that's a very rare combo, right?

[00:00:52] The numbers, the creativity, the courage that goes with it.

[00:00:55] So I am incredibly excited about our conversation partner today.

[00:01:00] I'm pretty excited also.

[00:01:02] He's had such a senior role.

[00:01:04] When you think about an economist, the truth sets you free, right?

[00:01:08] So we're in a healthcare industry that needs change.

[00:01:13] And we've been talking so much about the integrated healthcare model, integration in dentistry

[00:01:18] where we talk better with the colleagues, but also the colleagues of dentistry can talk

[00:01:23] to the medical side.

[00:01:25] And how is that going to happen?

[00:01:26] It's going to be so interesting to hear Marco's take on this, some of these problems, solutions

[00:01:32] of what change would look like.

[00:01:35] And at the end of the day, we all have a choice to make.

[00:01:38] Do we take this change in front of us as doomsday scenario and see it as a threat to what we're

[00:01:45] doing today?

[00:01:46] Or do we see it as an opportunity?

[00:01:49] And there I say, there we say the golden age of dentistry coming up around the corner.

[00:01:54] And so let's get into it and see if this is truly a doomsday scenario or the opportunity

[00:02:00] that we might all be have been waiting for.

[00:02:03] I know you and I being eternal optimists, I know where we fall on that.

[00:02:06] So let's go.

[00:02:07] And I look forward to this podcast.

[00:02:10] Hello everyone and welcome to another exciting episode of the Think Oral Health podcast.

[00:02:15] I am pleased to share with you our conversation partner for today.

[00:02:20] Dr. Jonathan Levine and I are welcoming Dr. Marco Vujicic who is currently the chief economist

[00:02:27] and vice president of the Health Policy Institute at the American Dental Association.

[00:02:32] Some of you may know him previously as the senior economist with the World Bank in Washington,

[00:02:37] D.C.

[00:02:38] Personally, I'm very pleased to welcome another economist with a perspective of a business

[00:02:43] side into clinical and oral health.

[00:02:46] The little known fact about Marco is that he is a Canadian.

[00:02:50] So we're very excited to bring a Canadian to this conversation.

[00:02:53] And he also, he started his career as a ski instructor.

[00:02:58] So for those of you who are braving the ski slopes on the East Coast, you know,

[00:03:02] if you're on the East Coast, you could ski anywhere.

[00:03:04] Marco, welcome to the podcast.

[00:03:06] And we now know you don't like easy things if you're skiing on the East Coast and if

[00:03:10] you're taking on oral health and being an economist.

[00:03:13] We like people who take on big audacious objectives here.

[00:03:16] You got it good.

[00:03:17] So we'll talk about that in dentistry.

[00:03:19] But no, I'm super happy to be here.

[00:03:21] I'm excited to talk to you both and see where we can go.

[00:03:25] All right.

[00:03:26] So how about we just kick it off with the baseline, Marco.

[00:03:28] Give us the baseline.

[00:03:30] You have the data, you're looking at it longitudinally.

[00:03:33] What is the state of the dental practice today?

[00:03:36] And what are the key challenges that you're seeing in this post-pandemic world that regular

[00:03:41] dentists or dentists that are part of a larger organization like the DSO need to be thinking

[00:03:47] about?

[00:03:48] Sure.

[00:03:49] All right.

[00:03:50] And then just where am I drawing this?

[00:03:52] As you've heard, I lead a group called the Health Policy Institute.

[00:03:55] And just think of us as like data wonks.

[00:03:57] So we're like a think tank within the ADA.

[00:03:59] We crunch a lot of numbers.

[00:04:01] So a lot of the insights I'm bringing are based on that.

[00:04:04] But to get to your question, look, there are two big things right now that are super pain

[00:04:09] points.

[00:04:10] One is staffing shortages.

[00:04:12] And I'll talk a little bit about that.

[00:04:14] And the second is reimbursement and other pain points with insurers.

[00:04:19] Right?

[00:04:20] So I source a lot of data from a representative sample of dental practices across the board,

[00:04:25] right?

[00:04:26] DSOs, large groups, small practices, solos, et cetera.

[00:04:29] The last time we surveyed folks at the end of last year, we asked a series of questions

[00:04:34] about looking ahead to 2024.

[00:04:37] What do you see as the biggest challenges?

[00:04:39] And with staffing, I got to reiterate, the thing is we have roughly 90% of practices

[00:04:46] saying it's super difficult to recruit hygienists or assistants, okay?

[00:04:50] Among those that are on the job market.

[00:04:52] What's concerning me is that data point has not changed in 12 months.

[00:04:57] So it is a significant issue and it has not improved.

[00:05:02] Now we'll talk a bit, hopefully it has to be what I think in the next 18 months.

[00:05:06] That's issue number one.

[00:05:07] Number two is we have-

[00:05:09] Marco, could you reconcile that data point with the fact that we're seeing record admissions

[00:05:13] in hygiene schools and dental schools.

[00:05:16] So how do you look at those two data points as a data wonk?

[00:05:20] How do you look at those two data points and reconcile them?

[00:05:23] There's simply a lag.

[00:05:25] So admissions took a nosedive big time during COVID.

[00:05:28] They are now on the upswing, right?

[00:05:31] So we've had two or three years now, and I just posted this the other day on LinkedIn.

[00:05:35] We've had two, three years now of steady increases in admissions, in hygiene programs.

[00:05:40] And in 2023, last fall, we had the highest level ever.

[00:05:44] Almost 9,000 admissions in hygiene programs.

[00:05:48] That takes a couple of years to trickle into the job market.

[00:05:51] Two years ago, 18 months ago, I predicted we're not going to get out of this labor shortage

[00:05:56] quickly because it takes some adjustment for the pipeline to adjust.

[00:06:01] We're finally seeing that, but it takes a couple of years for those admissions to trickle

[00:06:05] into graduates and then to trickle into the job markets.

[00:06:09] In 18 to 24 months, we will see that incoming grad class and hopefully ease some of the shortages.

[00:06:16] So great point, Maria.

[00:06:18] And the second issue around the third-party pairs is, again, this is a theme I want to

[00:06:25] drive home and I want to talk to you both about.

[00:06:27] My theme in 2024 is margin compression.

[00:06:32] So we are seeing squeezes on the reimbursement side for various reasons we could talk about.

[00:06:38] I don't know where those will go, but if you ask me right now, we've seen pretty steady

[00:06:43] trends of reimbursement rates to dentists from insurers not keeping up with inflation.

[00:06:48] They've been rising, but not at the same rate of inflation.

[00:06:52] Whereas the expense side, staffing, equipment, even to some extent PE.

[00:06:58] Yeah, supplies, consumables.

[00:06:59] Right.

[00:07:00] We've seen those costs rising.

[00:07:02] So there is this squeeze and we got to face up to this.

[00:07:06] That's not going to go away in the immediate term here, in the short term.

[00:07:10] Marco, just to clarify this, you're touching one of my favorite topics around insurance

[00:07:16] models and reimbursement models.

[00:07:18] And I call it the payments infrastructure because you refer to it as insurance.

[00:07:24] In reality, are you distinguishing between dental benefits plans and medical insurance

[00:07:30] when you say compression of margin?

[00:07:32] How do you think about the role of dental benefit plans versus medical insurance coming

[00:07:37] in for some of the services and paying for some of the services that are delivered in

[00:07:41] the dental office?

[00:07:42] Well, I'm talking your classic private insurance dental benefit.

[00:07:47] I use insurance, I use it loosely.

[00:07:49] Let's clarify.

[00:07:50] So you're right, as economists, it's not true insurance in the sense of protecting against

[00:07:56] catastrophic costs and risk and all that.

[00:07:58] And now listeners are well versed in a distinction because Jonathan and I always go back to when

[00:08:02] you get a dental insurance, what you're getting is predefined set of services at predefined

[00:08:06] cost.

[00:08:07] Let's call it a benefit.

[00:08:08] And that's it.

[00:08:09] You're not, yeah.

[00:08:10] Yes.

[00:08:11] But the providers, the force I'm talking about, the reimbursement kind of stagnation, that's

[00:08:16] irrelevant to the type of risk model it is.

[00:08:19] It's just simply how we're paying you.

[00:08:20] I want to talk, let's get into the future of dental insurance.

[00:08:26] To close this loop, I feel in 2024, we're getting to perhaps some kind of tipping point

[00:08:35] because our latest round of data show a significant share of practices, 40% saying in 2024, they

[00:08:44] plan to drop out of at least some of the networks there in terms of insurance.

[00:08:50] Now, we haven't seen those kinds of numbers ever in terms of how high that is.

[00:08:55] So I could be reaching a point where the practices are saying, I don't think it's, I'm getting

[00:09:00] out of the insurance provider network full bore.

[00:09:04] I don't think it's that.

[00:09:05] I think it's let me be a little bit more selective about what networks I'm in, what plans I accept

[00:09:11] versus, oh, I'll take any kind of patient.

[00:09:14] Right?

[00:09:15] So I don't know, maybe that will lead to some changes in 2024.

[00:09:19] But as of now to go back to big pain points, the hiring, the shortages of labor.

[00:09:25] And as we said, 18 to 24 months, I think that will ease, but not immediately.

[00:09:29] And then this third party payer pain points.

[00:09:32] Again, we'll talk about how that ends.

[00:09:34] But right now it's to me looking like dentists are potentially saying I need to be more selective

[00:09:41] on which plans I'm in and out.

[00:09:43] And if I could just throw out to us, no, look, there's a large percentage of the overall

[00:09:49] dental revenue is 127 billion and growing in the next few years, always at about, I

[00:09:56] don't know, 3%, 4% CAGR.

[00:09:58] When we're looking at this whole industry, we have the fee-for-service dentist.

[00:10:02] Now you're looking at one, Prostanon, it's multi-specialty dental clinics, started a

[00:10:06] bunch of companies.

[00:10:07] But I look at it also on the fee-for-service side.

[00:10:10] The compression and the largest cost on a PNL or a provider is headcount.

[00:10:16] And so here you have the hygiene cost per hour is going up.

[00:10:21] You have consumables going up.

[00:10:23] And as Marco said, you have this compression on the margin and there's gotta be a tipping

[00:10:28] point where the dentist saying a little bit raised their hand and they say no mass, like

[00:10:32] I can't run a business like this.

[00:10:34] But then let's think about the fee-for-service side, American Dental Association, who is accountable

[00:10:40] to all of dentistry of on the fee-for-service side, how do the fee-for-service docs address

[00:10:46] this issue?

[00:10:48] And they have this advantage because they're not getting compressed on their pricing that

[00:10:53] they can have a coordinated fee service raise in relationship to inflation and the cost

[00:11:01] of goods and expenses.

[00:11:02] Marco, maybe you can talk a little bit about that from an economist standpoint and a data

[00:11:06] point standpoint.

[00:11:07] Yeah, is that what you're saying?

[00:11:08] If you're a fee-for-service dentist, you have more of your ability to weather that

[00:11:12] margin compression is higher.

[00:11:14] Is that what I'm hearing you both say?

[00:11:17] And Jonathan is completely right.

[00:11:19] Here's the challenge.

[00:11:20] That market from the patient pool is shrinking.

[00:11:24] So this is a really important point I want to bring in.

[00:11:28] We did a very detailed analysis.

[00:11:31] Think about taking all the butts and chairs in America.

[00:11:34] Select the patient pool of 160, 170 million people that go to the dentist.

[00:11:39] And we track over time, how are they paying for their care?

[00:11:43] Are they insured?

[00:11:44] Are they out of pocket fully?

[00:11:45] Like to Jonathan's point, a fee-for-service patient.

[00:11:48] Are they Medicaid covered?

[00:11:49] Are they Medicare covered?

[00:11:51] Because Jan 1, now Medicare is starting to pay for some select services for people.

[00:11:55] Okay.

[00:11:56] Long story short, we see a significant expansion of the patient pool that is covered by private

[00:12:04] dental benefits.

[00:12:06] We see a significant shrink in the patient pool that is fully out of pocket payment and

[00:12:12] uninsured.

[00:12:13] And then the Medicaid, depending on the timeframe we look at, in some timeframes it's ballooned

[00:12:18] like post ACA.

[00:12:19] In the last five years, it's actually stabilized.

[00:12:22] So Jonathan, my point is yes, if you're a dentist, that would be a market where you can avoid

[00:12:29] some of these pain points that we talked about through third-party payers.

[00:12:33] The challenge is that patient pool is actually shrinking.

[00:12:36] So we can't have more and more dentists going after that market.

[00:12:41] And I want to say this really bluntly, and this is very controversial, but it's just

[00:12:44] my take on the data, right?

[00:12:46] We can't be telling all the new grads coming out of dental school, you know what?

[00:12:50] You don't need to be in insurance networks.

[00:12:52] You can make a great practice just being full fee-for-service like Jonathan, right?

[00:12:57] They can't all do that.

[00:12:59] It's a great market.

[00:13:00] It's a niche market.

[00:13:01] It's segmenting of the patient pool, but on mass, it's not a growing sector of the patient.

[00:13:07] But Marco, knowing where is right down the middle of the highway.

[00:13:12] How did these young dentists then, and maybe they're joining a DSO or they're joining an

[00:13:15] existing practice, and look, you got 22, 23% of the industry being DSOs and growing exponentially

[00:13:21] as we all know.

[00:13:23] Isn't there a middle ground?

[00:13:24] As you say, you have growth in the private dental type programs.

[00:13:28] So maybe we need to think about what is that middle ground that addresses the dental insurance

[00:13:33] or the dental benefit world, but also addresses the ability to deliver care at a high level

[00:13:38] as it relates to technology and all the things that are the headcount and quality people

[00:13:43] and training and all the things necessary to really build a robust dental practice that

[00:13:49] addresses the needs of the patient.

[00:13:51] Where is that?

[00:13:52] One better, forget the middle of the road.

[00:13:53] Why don't we work full press, full court press on actually fixing this broken dental

[00:13:59] insurance model?

[00:14:01] So Jonathan, you're right.

[00:14:02] We're stuck and I'm very blunt about this.

[00:14:05] We are stuck with the worst of both worlds, so to speak.

[00:14:09] Right now, we have an insurance paradigm in dentistry that's broken for the patient, for

[00:14:14] me.

[00:14:15] Why all of a sudden does my treatment plan stop at $1,200, $1,400, $1,500 that has nothing

[00:14:21] to do with my clinical needs?

[00:14:23] Okay, for the provider side, we've talked a lot.

[00:14:26] It's also broken, right?

[00:14:28] Clinicians can't do the care that's medically necessary and can't get me back into optimal

[00:14:32] oral health because I have this whole set of rules that are not science and clinical based,

[00:14:37] but the market is the market.

[00:14:38] So my point is, I see the huge opportunity, Jonathan, is to reform and regulate this private

[00:14:47] dental insurance model in a way that now benefits patients and clinicians, and you know who

[00:14:52] it won't benefit, right?

[00:14:54] So I got to tell you, this is priority one within the ADA and our DC team and our advocacy.

[00:14:59] There's been a lot of great activity.

[00:15:01] For example, in Massachusetts, we have something called medical loss ratio requirements.

[00:15:06] It's a way to regulate insurance so that, hey, if you bring in X dollars in premiums,

[00:15:12] you have to pay out 83% of that in claims.

[00:15:16] You can't just keep it all in administration and profits.

[00:15:19] So that's a reform that January 1 went into effect in Massachusetts.

[00:15:23] Many other states are doing it.

[00:15:25] We're working hard in DC at the federal level that ERISA reform and these larger things

[00:15:31] trying to regulate this insurance so it actually behaves like true insurance.

[00:15:34] I think that's more important, Jonathan, than trying to, in a sense, accept this status quo

[00:15:40] and find some middle ground.

[00:15:41] How do you do it?

[00:15:42] So I think that's big.

[00:15:43] I love that you went there because the DLR, I mean, I'm not saying that it's not a good

[00:15:48] DLR, and I got to tell you, we all have seen the parallel to this in the medical side,

[00:15:53] the medical loss ratio versus the dental loss ratio.

[00:15:56] And at a conceptual level, we see that it makes sense to us, the insurer, to make sure

[00:16:03] that they do what they're paid to do, right?

[00:16:06] Some of the premiums are going to actual clinical claims rather than administrative work.

[00:16:12] And that would, at least in an ideal state, encourage all of these benefit providers to

[00:16:18] be more efficient.

[00:16:20] That said, though, what we've seen, the way this has played out on the medical side is

[00:16:24] that even though we've had MLR, medical loss ratio, on the medical side for decades now,

[00:16:30] we're seeing that it becomes effectively the battle for the denominator.

[00:16:34] What is qualified as medical expense and what is qualified as admin expense?

[00:16:40] In effect, we haven't seen the cost of care come down dramatically after the MLR has been

[00:16:47] adopted on the medical side.

[00:16:49] So I love that you're going there because I think there is an opportunity to redesign

[00:16:54] and make the dental benefits industry more effective and help with access to care and

[00:17:01] higher quality care.

[00:17:02] I don't know if just passing a DLR is the answer.

[00:17:06] We need to make sure that once it's...

[00:17:08] The work doesn't stop there because we need to make sure that both the benefit companies

[00:17:12] and the patients and the providers are actually behaving in the intent of the law rather than

[00:17:19] trying to maximize where things are qualified.

[00:17:21] You're absolutely right.

[00:17:22] So it's not a panacea, to be clear.

[00:17:24] So it's not a silver bullet.

[00:17:25] I love how you frame this up.

[00:17:27] To me, it's one tactic in a larger kind of game plan to bring accountability and reform,

[00:17:34] right?

[00:17:35] The MLCA, the MLR was one provision, right?

[00:17:38] There was also a lot of other provisions saying we will define an essential health benefit,

[00:17:43] right?

[00:17:44] The Affordable Care Act did that for the first time.

[00:17:46] It said if you sell insurance, you must cover these 10 essential services.

[00:17:50] Okay?

[00:17:51] So there was another thing that said, frankly, I feel we need some of that in dentistry.

[00:17:56] Like you look at these ads late at night on TV and what they're selling in terms of Medicare

[00:18:01] Advantage and you get dental and you look at the data.

[00:18:03] It's okay.

[00:18:04] This is some of these plans are covering one visit and that's it.

[00:18:07] That shouldn't be the case, right?

[00:18:08] I think there's a need to define an essential oral health package of services that's core

[00:18:15] and regulate that.

[00:18:16] MLR is another one.

[00:18:18] It's another thing.

[00:18:19] The Affordable Care Act put in out-of-pocket limits.

[00:18:23] So a family cannot incur more than, I don't know what it is today, $15,000 in out-of-pocket

[00:18:29] healthcare costs.

[00:18:30] So if you get really sick pre-ACA, you would potentially have to go bankrupt.

[00:18:36] If you have coverage now under the medical side, again, it's governed by the ACA regs

[00:18:42] and you get super sick, like your out-of-pocket is limited.

[00:18:46] Not what the insurer pays, which is our world, right?

[00:18:49] So our world does the insurer liability is limited.

[00:18:53] Whatever it is, $1,500 on average.

[00:18:56] Sick or healthy, Marco, you're on the hook.

[00:18:58] Only after that, you want to do crowns and endo and all this.

[00:19:02] Great.

[00:19:03] But once you run out of the money, you're on the hook.

[00:19:05] So my point is we're dancing around this issue, right?

[00:19:08] The bigger picture, Maria, I think that you're raising is, and maybe this is not to go into

[00:19:14] detail here today, but because dentistry is governed outside of broad healthcare, frankly,

[00:19:21] the plans are exempt from so much regulation.

[00:19:25] And a lot of this regulation really makes sense.

[00:19:28] And I think that's something maybe we missed along the way.

[00:19:32] There's a strong desire for independence among clinicians.

[00:19:36] People want to keep dentistry separate and not part of healthcare and all that.

[00:19:41] There's consequences.

[00:19:42] I'm not saying do it or don't do it, but understand the consequences.

[00:19:45] The consequences are that the plans were also exempt from a lot of these accountability

[00:19:50] regulations and that's where we are today.

[00:19:53] But I think there's a way to change this.

[00:19:55] And what's the role of dentists?

[00:19:57] Like Jonathan is the outlier here who is a pioneer and who loves change.

[00:20:02] Probably he is in a, in the very much the, I would call it a minority of the dentists

[00:20:07] we practice today.

[00:20:09] Change is a scary thing.

[00:20:12] It's going to require a lot of change to take dentistry from a trade that's being on its

[00:20:18] own, doing its own thing to an integral part of the team, clinical or health team for a

[00:20:26] patient.

[00:20:27] And so how do you as part of the health policy institute at the ADA, how do you see the role

[00:20:32] of the dentist changing so that we could have this integrated view of what is the necessary

[00:20:40] intervention and treatment for the patient irrespective if it lives on the dental side

[00:20:44] or in the medical side, because practitioners are oral physicians, oral health physicians

[00:20:49] like Jonathan here are talking about C.

[00:20:52] They're talking about A1C levels, right?

[00:20:55] It's just, what is the role of the dentist here and how do you see the path to creating

[00:20:59] more of those integrated health staff?

[00:21:01] Now you're getting it Maria, that's where we want to go.

[00:21:05] But Margot, this is all about connecting the dots of oral health and overall health.

[00:21:09] And I do think where Maria is going is an exciting place within the context of the reinvention

[00:21:14] of the dental insurance.

[00:21:16] Because if we go upstream in dentistry, they go to the dentist or they go to their physicians

[00:21:21] and we're looking at blood pressure and even the basic vitals and we think wellness versus

[00:21:26] sickness model, we can save insurance companies millions of dollars and dentistry can become

[00:21:31] part of the healthcare system the way it needed to be.

[00:21:34] I love that question Maria and it's the heartbeat of what we love to talk about.

[00:21:39] Look, I'll be very clear.

[00:21:42] I think we are about to enter a golden age for this profession.

[00:21:47] I feel we have an opportunity and we're at a crossroads with all the trends and forces

[00:21:53] going on to really redefine and elevate dentistry and leverage dental care providers in ways

[00:22:00] we've never done before.

[00:22:02] It is super exciting.

[00:22:03] As Jonathan mentioned, there's people that are walking heart attacks waiting to happen

[00:22:08] that are seeing their dentist, but they're not going to any sort of other primary care provider.

[00:22:13] What if dentists were actively engaged in screening for these chronic conditions and

[00:22:20] reimbursed for it?

[00:22:22] That's complicated.

[00:22:23] Jonathan, data systems.

[00:22:25] I don't know your personal practice, but how many practices are using something like an

[00:22:29] epic patient record that is easily integrated, right?

[00:22:33] Very few.

[00:22:34] But that's where the future is going.

[00:22:37] I see dentistry finally being able to flex its muscle as the beacon of prevention, leveraging

[00:22:44] dentists as an additional touch point to the population to leverage all the preventive

[00:22:49] care not in the mouth, but taking salivary diagnostic, taking basic vitals in the office

[00:22:55] and somehow getting rewarded and reimbursed through that.

[00:22:59] That's the challenge, but that's not going to happen if we keep wanting to be separate

[00:23:04] and not part of healthcare.

[00:23:06] We're at this road where you got to almost reimagine what the profession is.

[00:23:11] And I certainly have my viewpoints on where the young generation of dentists sees themselves.

[00:23:16] I think it's much more open to this.

[00:23:18] Let's be core primary care providers.

[00:23:20] And by the way, there'd be millions of more people coming into the dental offices as well.

[00:23:24] Can you imagine if every newly diagnosed diabetic in America in 2024 automatically had to go

[00:23:31] get a dental screening?

[00:23:32] Thank you.

[00:23:34] This is millions of more people coming into dental offices, right?

[00:23:38] Okay.

[00:23:39] Maybe we're super busy today and we don't have the staff to absorb them, but I mean,

[00:23:43] we'll fix that.

[00:23:44] You're talking about expanding the reach and the power of oral health.

[00:23:48] And I feel things are aligning.

[00:23:50] That's why I'm super excited.

[00:23:52] So this is an economist excited by the way.

[00:23:56] This is always as exciting as it gets.

[00:23:59] You are absolutely right because we are looking at it from the oral health perspective.

[00:24:04] Outsiders are looking at this space and actually happen to agree with you, right?

[00:24:08] I was just at a conference with Judy Faulkner, the CEO founder of Epic.

[00:24:12] We know, actually, I don't know if our audience knows, but Epic looks at oral health and the

[00:24:18] dental space as their next frontier for growth.

[00:24:21] Not only are they developing the kind of a dental specific product that is being piloted

[00:24:27] with Pacific Dental, but they also are having a team that is right at the core of their

[00:24:33] new product offering.

[00:24:34] So when you talk about dental as an opportunity for integrated care delivery, that's if we

[00:24:41] don't do it on ourselves from as the people who are doing dentistry, dentistry, the outsiders

[00:24:47] are going to come in.

[00:24:48] Right?

[00:24:49] What's your reaction?

[00:24:50] Like you're, you're in the front lines, right?

[00:24:52] So is this, do you feel like most dentists are like, interesting, but like what I'm doing

[00:24:57] the dental part only, or do you feel they're excited en masse for this new opportunity?

[00:25:02] It's a great question.

[00:25:03] Look, for me, it always comes down to leadership.

[00:25:06] The leadership has to drive certain changes.

[00:25:09] The changes we're talking about within the industry.

[00:25:11] If those changes are in place, the word dentist is a problem.

[00:25:15] We have to rebrand the industry.

[00:25:17] We're oral physician, number one.

[00:25:19] 58 systemic inflammatory diseases directly correlate to inflammation in the mouth as

[00:25:24] we know.

[00:25:25] The pH of the mouth is a huge indicator of health in the mouth.

[00:25:28] Stylopathy diagnostic.

[00:25:30] In my practice, I'm multi-specialty.

[00:25:31] I'm prosthodontist, two other prosthodontists, I'm periodontist, two orthodontists, ceramist,

[00:25:37] the whole thing.

[00:25:38] But the hygiene room is the center of innovation.

[00:25:41] Stylopathy diagnostic, basic, standard of care.

[00:25:45] Anybody with inflammation, CBCT, standard of care.

[00:25:48] Everybody gets a CBCT.

[00:25:50] Less radiation, much more information.

[00:25:52] I got bite wings off the new Ray Scan and Planvaca, and all of them, all the new CBCTs.

[00:25:58] Everybody gets scanned.

[00:25:59] Everybody gets an internal scan.

[00:26:01] If we had reimbursement for mad appliances for CBCT and scanning, we would be able to

[00:26:06] get very upstream in a preventative model.

[00:26:10] Why?

[00:26:11] Because hypertension, diabetes, and cardiovascular disease is directly related to how well people

[00:26:15] get into deep regenerative sleep.

[00:26:17] We need leadership.

[00:26:18] So I think practices like mine, these kind of conversations with people who could really

[00:26:23] start reinventing how we think about benefits and dental insurance and drive that, especially

[00:26:30] with this young generation.

[00:26:32] This young generation, it's exciting for everybody because the dental schools are now training

[00:26:37] them on digital workflow, all the new technologies.

[00:26:41] And our diagnostics are really going deep.

[00:26:44] And as we were saying, people come to the dental office more than they come to physicians.

[00:26:48] So if they're able to share on a universal health record, and I'm working on some things

[00:26:52] where we're looking at patient portals for our patients so they have access to all that

[00:26:56] care.

[00:26:57] The dental model is broken.

[00:26:59] I'm going to send to a periodontist, I have a perio issue, I'm not going to get an information

[00:27:04] or call back maybe in two weeks, they're going to lose my records.

[00:27:08] And here we go again, and they steal the patient of the general dentist.

[00:27:11] So that's over.

[00:27:13] That's over.

[00:27:14] So we have specialists, restorative dentists, the general dentist in an ecosystem, shared

[00:27:18] information with an integrated business model of medicine and dentistry and integrated within

[00:27:22] dentistry.

[00:27:24] We've been so fragmented, but you said something so true, we have such a convergence of trends,

[00:27:28] it's feeling it now.

[00:27:30] Things can really change.

[00:27:31] But I think it does take leadership and I think the group like the American Dental Association

[00:27:36] can drive some of this change, rebrand what a dentist, who they really are, and really

[00:27:41] build the roadways to this integration and to make the change.

[00:27:47] And God bless this new generation because they got the energy, they're going to bring

[00:27:50] the energy to make the change.

[00:27:51] Dentists make people healthy.

[00:27:53] This is not just about the mouth.

[00:27:56] Dentists make, or the dental team makes people healthy.

[00:27:59] So the point is, let's position ourselves that way.

[00:28:03] Let's get reimbursed that way.

[00:28:04] And then what are the rules?

[00:28:05] I love that you said like at the ADA, this is where honestly we have an incredible influence.

[00:28:11] We have a great lobbying arm.

[00:28:13] What are the rules and regs that need to change to unleash the power of Jonathan and his team?

[00:28:19] You know what I mean?

[00:28:20] Because there's so many things standing in the way right now.

[00:28:23] And how do we de-risk and make this change less scary?

[00:28:26] And make it less scary, right?

[00:28:28] But I think that's part of educating and identifying the opportunities and all that.

[00:28:32] And there's a lot of, this is not, this is boring stuff, but there's a lot of nitty gritty

[00:28:37] that I think people don't understand goes on behind the scene.

[00:28:41] Like electronic information exchange, the fact that a record from Jonathan's office should

[00:28:46] talk to a record from another office and should talk to a physician's record in a seamless way.

[00:28:52] There are technical specs like the ADA does so much of this behind the scenes, right?

[00:28:57] AI, we can touch on this, but AI is going to revolutionize dentistry.

[00:29:01] Great.

[00:29:02] Make sure there are proper standards on what that AI is doing, right?

[00:29:07] We're working on that.

[00:29:08] So this is very non-dramatic stuff, but in the end of the day, providers I feel don't

[00:29:14] understand how important it is that kind of these behind the scenes regulations go on.

[00:29:19] And we do that every day.

[00:29:21] Look, if we take the new innovation, we take new technology, salivary diagnostics, understanding

[00:29:26] of sleep, the new CBCT, the cone beams that we have for our patients, there becomes some

[00:29:32] reimbursement model, some benefit model for this prevention.

[00:29:37] We drive more people to the dental office than we have an integrated healthcare model

[00:29:40] with our medical colleagues.

[00:29:42] You take a blood pressure, it's high, it's up, cardiologists, internists need to know

[00:29:46] about it.

[00:29:47] We could prevent an event from happening on and on of going to a wellness model.

[00:29:52] But integrating the service side coupled with these young dentists, the young energy coming

[00:29:57] out with the proper changes coming from places like the American Dental Association, because

[00:30:02] we need to architect this change.

[00:30:03] It's happening.

[00:30:04] It's happening.

[00:30:05] It's going to come.

[00:30:07] I think all three of us are optimists, Maria.

[00:30:09] We are optimists.

[00:30:10] You heard it here.

[00:30:12] Dentistry is about to enter in the golden age of dentistry.

[00:30:16] And so this is, it's ours to make the most out of it.

[00:30:20] And I go back to, I think we covered the role of the dentist.

[00:30:23] We covered the role of organizations with huge influences and platforms like yours.

[00:30:28] We covered the role of plans providers a little bit.

[00:30:32] What do you think the role of the patient needs to be and how does it change?

[00:30:38] And what is also the role of the ultimate payer?

[00:30:42] Because when we talk about there's this misnomer that insurance company pays for the claim,

[00:30:46] it's actually the self-insured employer or CMS.

[00:30:50] And so is there any talking about rebranding and reframing the conversation to the self-insured

[00:30:56] employer?

[00:30:57] Walmart spends $2 billion on healthcare costs for their employees and their dependents.

[00:31:03] That's not a small amount on the P&L of a company.

[00:31:06] So how do we need to engage patients differently, self-insured employers differently to bring

[00:31:13] them along in that future state of oral systemic health?

[00:31:16] I love the question.

[00:31:18] I don't, I can give you some thoughts, but that is the next right question.

[00:31:23] On the employer side, I think we need to rebrand what Jonathan said, the value proposition

[00:31:30] of oral health and by surrogate, the dental benefit employers are buying for their employees

[00:31:35] or self-funding.

[00:31:36] This idea of, okay, we'll take the status quo to checkups a year, this and that, maybe pregnant,

[00:31:42] maybe diabetes, you get some enhanced benefit.

[00:31:44] That's the next innovation we're seeing in the market.

[00:31:47] I think we need to step back and say, let us absolutely rethink all of this.

[00:31:53] So one thing there's a group of us under the World Economic Forum that have started an

[00:31:58] oral health interest group that is trying to now talk to Fortune 500 communities, to

[00:32:04] the CFOs to say, look, your employees will be healthier, happier, miss less work, be

[00:32:12] more productive.

[00:32:13] If you have...

[00:32:14] More loyal.

[00:32:15] They're more likely to stay with you.

[00:32:17] If you have a true comprehensive dental benefit that actually gets their mouth back to a true

[00:32:22] speak smile happily, not these procedures are covered.

[00:32:26] These are not this many times, not get the mouth back to optimal oral health.

[00:32:31] So I feel we're starting there, but we need to do that Maria.

[00:32:35] We need to be in different circles.

[00:32:37] We need to be talking to financial people.

[00:32:40] Jonathan mentioned all the cost savings, right?

[00:32:44] It's not a public health ministry of health conversation.

[00:32:46] That's literally the CFO in the ministry of finance.

[00:32:49] That's exactly right.

[00:32:50] It's not even the head of benefits, right?

[00:32:52] We have huge respect for the folks that had a benefit.

[00:32:55] They're trying to do so much with little resources.

[00:32:58] This needs to be a C-suite conversation.

[00:33:00] So that's part of leadership, right?

[00:33:02] We were like, okay, and this was in partnership with Colgate and Henry Schein and the ADA.

[00:33:06] We're like, Hey, World Economic Forum, can you convene some conversations among the Fortune

[00:33:10] 500 community for us?

[00:33:12] So that's moving.

[00:33:13] That's an example on the public.

[00:33:15] I think that is a, I have two thoughts there, right?

[00:33:19] One is we are seeing more consumerism, that type of behavior of, I want outcomes, I want

[00:33:29] results.

[00:33:30] I want things super quick.

[00:33:31] I want things super convenient.

[00:33:33] I need to quickly be able to book a dental appointment and I want to know the quality

[00:33:37] and the outcomes and this guy and the price.

[00:33:39] So there's a whole wave of young generation consumers, patients bringing a consumerist

[00:33:45] attitude to healthcare and dentistry is caught up in that.

[00:33:49] I fundamentally think that's a good thing because I think it will push us to be much more patient

[00:33:54] centric, much more convenient for patients, much more transparent.

[00:33:59] The days of iPhone, a receptionist gives me options, they're over.

[00:34:04] This is a few clicks on your phone to book an appointment.

[00:34:07] It's not that I'll move on to the next provider.

[00:34:10] That's the future.

[00:34:11] The other thing is, I don't know how successful we've been in actually talking to the public

[00:34:19] about the value of oral health and I'm not an expert in this, although it doesn't stop

[00:34:23] economists from pontificating, but I think we are talking too much in an echo chamber

[00:34:29] to ourselves and I think we need to think of very different influencers or messengers.

[00:34:37] Like it's different if the dental community says you should do X, right?

[00:34:42] You should see your dentist boy C or you should, if you're, if are a high risk for

[00:34:46] diabetes, you should be going for screening.

[00:34:49] So let me take up on this.

[00:34:50] Yeah.

[00:34:51] A hundred percent agree with you.

[00:34:52] I believe we are, there are strong messages, but the, in that echo chamber of the oral

[00:34:58] health ecosystem, why is it that organizations with platforms like yours are not picking

[00:35:05] up on the data points?

[00:35:07] Like recently in January, as early as recently as January, there was an article about a former

[00:35:13] NFL player who died at 36 because he didn't treat his cavities and he had infection and

[00:35:21] sepsis and travel to his brain.

[00:35:23] And he flatlined when he fell at a construction site.

[00:35:26] Why is it that your association and is not partnering with these other sports athlete,

[00:35:33] professional sports associations to raise awareness because peak performance includes

[00:35:40] your oral health and pick your any other ones, the hockey league, the national basketball

[00:35:45] association.

[00:35:46] It's, it doesn't have to be the NFL only.

[00:35:48] So the door is getting open.

[00:35:51] It's the truth.

[00:35:52] Look at Andrew Huberman, look at Mark Hyman, look at all of the functional medicine doc,

[00:35:59] taking a different approach than Western medicine philosophy of a sickness model.

[00:36:03] Talking about nutrition, talking about sleep, talking about fitness, talking about mindfulness

[00:36:09] and stress management for longevity, all of these types of things.

[00:36:12] It's the same thing in dentistry.

[00:36:14] The collective healthcare model that now 20% of the GDP has to change.

[00:36:19] We got a problem.

[00:36:20] Everybody agrees with that.

[00:36:21] Okay, good.

[00:36:22] How do we get upstream?

[00:36:23] This whole conversation is literally about upstream.

[00:36:26] And I love what you said, Margo, about, about the consumerism because as Steve Thorne would

[00:36:32] say, right, our good friend from Pacific awareness drives consumerism.

[00:36:36] So now as the consumer really knows more and it's up to us to educate the industry, we

[00:36:42] need to educate.

[00:36:43] I'm doing my best.

[00:36:44] I got a book coming out next quarter called Get Oral.

[00:36:47] Could you imagine?

[00:36:48] My editor actually liked that name, but you got to grab people.

[00:36:52] This book is going to be all about the connection of the mouth and the rest of the body.

[00:36:56] And we need to elevate in the books all about elevating this profession.

[00:37:00] I love what you said, Margo, about elevating profession because we need to bring medicine

[00:37:04] and dentistry together for a more efficient business model.

[00:37:08] That's the heartbeat of it.

[00:37:10] Such a Maria, pretty exciting conversation.

[00:37:13] I'm calling out all the associations because I think that there is an opportunity.

[00:37:20] I think the door has been opened.

[00:37:21] We just need to have the guts to walk through it.

[00:37:25] And this is part of, forget about why we did it, why we didn't.

[00:37:29] We don't have yesterday again.

[00:37:31] Looking forward, I love what Jonathan said.

[00:37:33] We're all agreeing there's an opportunity here.

[00:37:36] And the idea now is, and Maria, you, I'm really glad you brought that example in, right?

[00:37:41] It's tragic, but it hits home and it is a different audience and it's a different

[00:37:46] set of messengers that need to carry this.

[00:37:48] And we can do this.

[00:37:50] It's just, it's different.

[00:37:51] Like there are, like it or not, you know, you mentioned Andrew Huberman.

[00:37:54] There's a lot of people that are very influential in terms of health behavior and stuff.

[00:37:59] Let's go talk to them.

[00:38:00] Let's go talk to them.

[00:38:02] Let's get Jonathan out on the road.

[00:38:04] Come on the ADA podcast.

[00:38:07] Let's get you out.

[00:38:08] Let's go.

[00:38:10] I have a thought and I want to share it with you, Mark.

[00:38:11] I would like to see the ADA go front and center with the corporate partners, the Colgate's,

[00:38:17] the Henry Shines, and whoever wants to join them and create a task that's with insurance

[00:38:22] companies and create a task force.

[00:38:23] And I want to have the clinicians like myself involved because we are at the front line

[00:38:29] and it's a practice like mine, the DSO CEOs or the clinical directors of a Pacific Dental

[00:38:35] that's navigating those roads of fee-for-service and benefits and get the collective to help

[00:38:42] drive the change because it's going to happen.

[00:38:46] But as we know that life is a team sport and so is healthcare.

[00:38:51] And we got to bring everybody together, all of our stakeholders together.

[00:38:54] I totally agree with you.

[00:38:56] And with one caveat, and this is important viewpoint of the world, A is Oral Health Pays

[00:39:02] Dividends.

[00:39:04] And it's really great.

[00:39:05] More people come into the dentist, tell the public about this and more people will show

[00:39:10] up and pay full fee out of pocket.

[00:39:13] That I feel is not necessarily the reality.

[00:39:16] To achieve that vision of millions of more people with a dental home, millions of more

[00:39:21] people knowing easily if I get screened for this condition, I know my nurse practitioner,

[00:39:28] my PCP, somebody, the CVS pharmacist is going to say, I'm filling your diabetes management

[00:39:34] meds.

[00:39:35] Let's ask you if you've had a dental screen in the past two years.

[00:39:38] To make that happen is not just giving messages to the public.

[00:39:41] It requires systems change.

[00:39:43] And we talked earlier about this, right?

[00:39:45] We talked about like, how do you, if people don't have good coverage and they're like,

[00:39:50] I can't afford this.

[00:39:52] What do we do?

[00:39:53] I feel there's a reform potentially there.

[00:39:55] Let's get good coverage that actually covers the services needed and is adequately funded.

[00:40:00] Okay.

[00:40:01] We're working on that.

[00:40:02] We're trying to get regulations to make sure that happens.

[00:40:04] My point is though, and we're both, you guys are both leaders on the disruptive change

[00:40:09] field.

[00:40:10] So I don't want to send the message that the model as it is today is going to be sustainable.

[00:40:16] We just need to get more patient traffic by making the case to consumers.

[00:40:20] It's going to require some systems change.

[00:40:22] And Jonathan, you said it right.

[00:40:23] We're already seeing this.

[00:40:25] We're seeing new early career dentists in different models than the previous generation.

[00:40:30] If you look at late career dentists today, 50% are in solo practice.

[00:40:34] If you look at early career dentists, it's 17%.

[00:40:38] So you mentioned Jonathan, 20 something percent of the market is DSOs.

[00:40:43] That's very different than five years ago.

[00:40:45] So I feel like we're already seeing the practice model evolves to actually enable the kind

[00:40:52] of reforms and change you're both talking about.

[00:40:54] So this is why it's exciting.

[00:40:56] I feel things are aligning, right?

[00:40:58] I guess that's our thing today.

[00:40:59] I don't think it's going to be hard.

[00:41:00] Hopefully our listeners are also hearing that change doesn't have to be hard.

[00:41:05] And it's the role of innovation technology and experts and influencers and decision makers

[00:41:11] like us here and our listeners to make that transition from dentistry of today to dentistry

[00:41:16] of tomorrow easier and less scary.

[00:41:19] Because I'll tell you what, your example.

[00:41:21] I go back to my conversation with Jodi Faulkner.

[00:41:24] Epic has the diagnosis of all patients who are diabetic.

[00:41:29] And so when the primary care physician sees the patient, Jonathan, a pop-up in Epic could

[00:41:35] say, has your patient, Jonathan being seen by a dentist?

[00:41:40] Click here to schedule an appointment.

[00:41:43] That's all we need to do.

[00:41:44] And Epic's already interested in looking at this and advancing that change.

[00:41:49] So it doesn't have to be any more complicated than a pop-up.

[00:41:52] And we can just pile on to our primary care physicians and oral health physicians to say,

[00:41:56] do more, ask more questions.

[00:41:58] We have to make it easy and integrate in the workflow.

[00:42:02] And that's already underway.

[00:42:04] That's the conversation where I think it needs to go.

[00:42:06] So last question as we close, Marco, if you had advice to those brave entrepreneurs looking

[00:42:15] to build solutions, grow companies in oral system health, where would you point them

[00:42:20] to explore?

[00:42:21] Where do you see the opportunity for the next billion dollar company in oral health?

[00:42:25] To facilitate meaningful collaboration with primary care.

[00:42:29] That's how I would say it.

[00:42:31] I feel that's the next frontier and there's tech problems to solve.

[00:42:36] There's data problems to solve.

[00:42:38] There's patient workflow, as you said, problems to solve.

[00:42:42] There's insurance reform that needs to happen.

[00:42:45] Okay.

[00:42:46] So it pops up, it says go for a dental screening.

[00:42:49] That person's I don't have coverage.

[00:42:50] Thank you.

[00:42:51] Bye.

[00:42:52] Okay.

[00:42:53] We don't want that situation.

[00:42:54] So I want to bring it back to, I really feel like positioning dentistry as a primary care

[00:42:58] touch point and promoting collaboration with primary care is the next frontier.

[00:43:04] And there are many ways that can happen, many models.

[00:43:06] But I feel if I asked the entrepreneur community work on that.

[00:43:10] Maria, this was just one of the most exciting podcasts we've had.

[00:43:15] Marco, you've been amazing because you're not just a numbers guy.

[00:43:18] That would you prove to us and we need this conversation to continue.

[00:43:24] I would love to hear what you're going to be working on, how Maria and I and people

[00:43:30] we know can be helpful in this effort because we're incredibly passionate about creating

[00:43:35] a more efficient or effective healthcare model for everyone.

[00:43:39] And I think we all share that vision.

[00:43:41] Please come back and keep us updated.

[00:43:43] Lastly, if our listeners want to get involved, hear more about what you're doing guys, please

[00:43:49] follow Marco on LinkedIn.

[00:43:50] He's really great at posting on the latest research and connecting to his network.

[00:43:55] How else can our listeners stay involved?

[00:43:57] So follow me on LinkedIn.

[00:43:59] We release a lot of research that way.

[00:44:01] So if you go to ADA.org slash HPI, there's an easy sign up to our newsletters.

[00:44:08] They connect it and you could also browse some of these economic updates that I've talked

[00:44:13] about, but you could connect with us that way as well.

[00:44:17] Thank you for joining us, Marco.

[00:44:18] Until next time.

[00:44:19] Thank you for having me.

[00:44:20] Super exciting.

[00:44:21] And this is a golden era coming.

[00:44:22] So thank you.

[00:44:29] Thanks for listening to the Think Oral podcast.

[00:44:31] For the show notes and resources from today's podcast,

[00:44:35] visit us at www.outcomesrocket.health slash thinkoral,

[00:44:42] or start a conversation with us on social media.

[00:44:46] Until then, keep smiling and connecting care.