Quick Bites Dental Service Organizations, or DSOs, are non-professional entities that manage the administrative, marketing and business side of a dental group practices on behalf of the group’s dentists. Approximately 10.4 percent of dentists nationally and 5.8 percent in Washington are affiliated with a DSO according to the ADA Health Policy Institute (HPI). The DSO market share varies significantly across age groups. One in 5 dentists under 35 years were affiliated with a DSO in 2019, according to HPI’s most current data. In 2017, the Legislature passed Senate Bill 5322, a bill supported by WSDA designed to provide stronger patient care and safety guardrails and to restrict third parties from interfering with the dentist/patient relationship.

For decades, US dental graduates could count on starting their own practice fresh out of dental school.

As the cost of a dental education has skyrocketed, the prospect of a recent graduate launching an independent dental practice has diminished. That’s what made the concept of Dental Service Organizations, or DSOs, a more attractive option for some.

DSOs provide back office support to dentists, managing the administrative, marketing and business side of a practice. To a new dentist overwhelmed by treatment demands and the practical aspects of managing an independent practice, DSOs may look enticing. 

As WSDA legal counsel Emily Studebaker explains, changing demographics and economics have shifted the dental practice model away from independent practices toward DSOs.

It’s a move that can solve some problems, but also can create new ones, if left unchecked.

“There was a time when dentists simply started their own independent dental practices after graduating. However, a one-size-fits-all practice model doesn’t work as well in today’s society,” said Studebaker. “Dentists today need to have the flexibility to contract for support, work for another dentist, or create or join a group practice of dentists.”

Many DSOs operate successfully, supporting dentists and their practices without cause for concern. But at times, DSOs have overstepped their role, shifting from supporting a dental practice to dictating to the practice and directing how dentists should provide care. Government reports, legal settlements, and firsthand patient and provider experiences provide many examples of interference from third-party for-profit corporations placing corporate profits ahead of patient care.

“When profit motives are put ahead of patient care and safety, and corporate judgment interferes with the independent judgment of the licensed dentist,” said Studebaker, “there is cause for concern.”

Successful Advocacy

For several years, the WSDA advocated in Olympia for legislation that would provide stronger patient care and safety guardrails and that restricted third parties from interfering with the dentist/patient relationship. A strong advocacy effort and increased media attention brought the issue to the forefront during the 2017 legislative session.

A compromise was sought by legislators hoping to resolve concerns from patients, dentists and DSOs. The resulting legislation, Senate Bill 5322, passed the Legislature unanimously in May 2017. The new law authorized DSOs to provide business support and management services to a dental practice and to receive fees for these services, as agreed to by the dental practice owner or owners.

“Legislators had been hearing emphatically from both sides that they were ready to find a resolution, resulting in pressure that brought both sides to the table,” recalls Studebaker. “While there were several legislators who were deeply engaged in the issue and deserve thanks, Sen. Curtis King and Rep. Michelle Caldier put in hours on this effort, in addition to their other legislative responsibilities, convening a series of meetings during which the issues were hashed out and a compromise bill was drafted.”

Under the law, DSOs may own or lease assets used by a dental practice, including real property, furnishings, equipment, instruments, materials, supplies, and inventory. However, DSOs may not own patient dental records.

DSOs are also allowed to employ or contract for the services of certain personnel.  However, a DSO may not employ or contract for the services of licensed dentists, licensed dental hygienists, licensed expanded function dental auxiliaries, certified dental anesthesia assistants, or registered dental assistants. Only a dentist licensed to practice in Washington may employ such staff.

Perhaps most importantly, the law made clear that a non-dentist – including a DSO – may not interfere with a licensed dentist’s independent and clinical judgement. A non-dentist third party may not interfere with a dentist’s right to access patient records or a dentist’s decision to refund any payment made by a patient for dental services performed by the dentist.

“Whistleblower” Protections

Another key component of the 2017 law was a series of “whistleblower” protections that shielded patients and dentists from retribution should they report any illegal activities under the new law.

“Under the law, if a dentist, patient, or other person is aware of undue influence over a dentist by a non-dentist, that person can make a complaint to the Washington State Department of Health concerning the unlawful practice of dentistry,” said Studebaker. The Department has enforcement power.  It can evidence and can hold the non-dentist legally accountable, including seeking action by the Attorney General.

The law also clarifies that any attending dentist is prohibited, without reasonable cause, from neglecting, ignoring, abandoning, or refusing to complete a procedure that is currently underway for a patient. Instead, a dentist must advise a patient of the termination of care and that the dentist will remain reasonably available for up to 15 days.  A dental practice owner who is discontinuing or moving a practice must also comply with these requirements.

DSOs are prohibited from intentionally preventing a dentist from complying with these requirements. If the dentist provides services on an employee or contract basis, the law clarifies that it is the employing dentist or entity that maintains responsibility for the patient, so the employed dentist will not be deemed to have abandoned the patient.

“While the 2017 legislation did not include every safeguard envisioned in WSDA’s original bill, the resulting law, along with existing state and federal law related to fraud and abuse, provides the state with strong enforcement authority to address third-party activities that interfere with the dentist-patient relationship,” added Studebaker.

“This law should serve as a deterrent against unlicensed practice and undue influence in DSO settings.”

With that in mind, the WSDA continues to work with enforcement agencies, including the Department of Health, Office of the Attorney General, and the Dental Quality Assurance Commission, to ensure that they are made aware of regarding instances where third parties have unlawfully interfered with the dentist-patient relationship. For example, in 2018, WSDA supported a whistleblower’s complaint against a DSO alleging it had directed its staff to reuse Isolite dental mouthpieces that are specifically designed and intended for single use only. In this instance, the whistleblower alleged that the practice exposed children, a high percentage of whom come from low-income, Medicaid-eligible families, to serious risk of infection and other complications.

WSDA remains ready to support whistleblowers who come forward with legitimate complaints about similar violations in other office settings. We believe that such efforts serve the interests of the public, the dental profession and our members. And of course, WSDA is also available to provide support and guidance for members who have concerns regarding non-dentist interference in their practice of dentistry.”

Clarifying the Limits on DSOs Under state law, non-dentists, including DSOs, may not limit or impose requirements on: The length of time a dentist spends with a patient Performing dental services The number of patients a dentist treats in a certain period of time The number of certain types of procedures a dentist completes in a certain time period A dentist’s decision regarding the course of treatment for a patient The manner in which a course of treatment is carried out by a dentist The manner in which a dentist uses dental equipment or materials The use of a laboratory or the materials, supplies, instruments, or equipment deemed reasonably necessary by a dentist to provide diagnoses and treatment consistent with the standard of care

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This article originally appeared in Issue 2, 2023 of the WSDA News magazine.