Jeff Parker is developing the first viable non-profit model of dentistry that is scalable and adheres to high standards of care in order to treat the millions of youth across the United States who currently do not receive oral health care.
The New Idea
Each year in the U.S., tens of millions of children, disproportionately low-income children, go without seeing a dentist. This lack of access to oral health care is a complex problem fueled by a number of factors, one of which is the relatively small number of dentists who participate in Medicaid.
Jeff Parker is developing the first viable non-profit model of dentistry that can provide quality care to the millions of American youth who participate in Medicaid. Whereas many in the dental field claim such an arrangement cannot work, Jeff’s Sarrell Dental model proves that Medicaid patients can indeed be treated equally and, if managed appropriately Medicaid reimbursements can sustainably cover the costs of a high-quality, full service dental practice. He does so by combining three reinforcing strategies: first, a robust community outreach strategy; second, a set of business practices and operations that maximize the chair utilization rate in each office and significantly reduces the cost of dental supplies; and third, a strong culture of care, with transparency and quality to ensure the best patient experience. A central innovation is the separation of business management from care delivery itself. Sarrell Dental now reaches 145,000 patient visits a year across 14 rural and low-income communities in Alabama. While resistance from the establishment has been strong, Jeff is confident that he is near a tipping point. They have now affiliated with the non-profit, Community Dental Care of Dallas, TX. Community Dental sees Dallas’ most vulnerable adults and children, providing for over 62,000 patient visits in 2013.
A majority of dentists across the U.S. do not participate in Medicaid. As such, a significant amount of America’s youth are not receiving adequate oral care. A recent study conducted by the Pew Charitable Trust found that in 2011, more than 14 million children enrolled in Medicaid did not receive any dental service and that in 2010, privately insured children were almost 30 percent more likely to receive oral health care than those who were publicly insured through Medicaid or other government programs.
Youth who do not receive oral care are susceptible to major health issues down the line, let alone having to deal with the social stigma of having bad oral hygiene. Dentists cite multiple factors for not participating in Medicaid; chief among them are low reimbursement rates and burdensome administrative procedures. Furthermore, there is a prejudice against Medicaid patients. Some believe that Medicaid patients do not show up for their appointments. Sarrell has proven this is not true when the patient is treated with dignity and respect.
Other issues emerge when it comes to the business side of dentistry. Most challenging, perhaps, is that state Dental Practice Acts that limit to non-dentist ownership of dental care centers and the American Dental Association (ADA)’s policy against non-dentist ownership. In the U.S., states regulate who can own and operate a dental practice; what entities may employ a dentist; and what level of control non-dentist owners and managers may have over a dental practice.
As of 2012, 26 states restrict non-dentist interference or ownership by making the act of owning a dental practice a defining element of practicing dentistry, while five states prohibit non-dentists from operating dental practices, and four states have either no laws addressing the issue or provisions that provide no guidance on how to classify ownership. Furthermore, The ADA, which is a powerful guide for policies and norms affecting dental practices across the U.S., has been a forceful supporter of only dentist-owned practices. This “norm” of non-dentists being excluded from leading a dental practice can result in inefficiencies on the business front, including not being able to allocate resources to work effectively with publicly insured patients.
Sarrell Dental was established in 2004 by retired cardiologist Dr. Warren Sarrell, with The Northeast Alabama Regional Medical Center donating space for the initial dental facility. After one year, the clinic was not operating with the desired impact, leading Dr. Sarrell to seek the advice of Jeff Parker, an businessman with a reputation for dynamic corporate turn-arounds and sound business skills.
Jeff took on the role of CEO in 2005 when the practice had only one clinic and serviced as few as 800 patients per year. As an experienced corporate business leader, Jeff quickly identified opportunities to refine Sarrell Dental’s business practices, Jeff developed three major guiding principles for Sarrell Dental, that when working in unison, produce the model to ensure that Medicaid and publicly-insured patients can access the highest quality oral health care.
First and foremost, Sarrell Dental institutes a high level of quality care and transparency throughout its practices. Sarrell Dental’s rapid growth called for increased attention to what Jeff calls a “Culture of Caring.” This culture has been operationalized in many ways, including: the clinic décor; expanded hours of operation; reminder phone calls; follow-up calls to inquire as to why an appointment has been missed; requesting the guardian to be present in the room while the child receives care; one-on-one education for guardian and child during the exam; and extensive community outreach efforts. Ultimately, the “Culture of Caring” runs deep across all employees of Sarrell Dental and impacts the patient experience. To date, and with over 550,000 patient visits, there has never been a single complaint filed against Sarrell Dental to the Alabama Board of Dental Examiners.
Secondly, Sarrell Dental leads community outreach efforts that are valuable opportunities to increase the program’s visibility, while also providing a variety of venues from which to identify new patients who do not already have a dental provider. Each of the 14 clinics has a full-time community outreach coordinator who works closely with county and local Head Start programs, day care facilities, schools, and other local organizations to organize free, basic dental screenings for children who provide signed consent forms. Community outreach coordinators also offer oral health education to children and guardians at health fairs, PTA meetings, mandatory Head Start guardian meetings, and during classroom visits. Sarrell Dental sponsors and conducts other community outreach activities on a more limited basis that showcases its Culture of Care. For example, during Christmas, Sarrell Dental brought “Santa” in to take free pictures with the kids in several communities.
On the side of transparency, Sarrell Dental employs a unique “rotating” dentist structure. Sarrell dentists are not assigned to a single clinic; instead, they work in different clinics on a daily basis. This function, managed by the Chief Dental Officer (CDO), results in a level of transparency and quality care that ensures children are treated fairly and optimized care is delivered to the patient. The CDO acts as an internal auditor in this regard, and Sarrell Dental has created systems to capture extensive notes which are reviewed by the dentist before the patient’s appointment.
Jeff has refined Sarrell Dental’s business strategies to produce the most cost-effective model. Sarrell Dental has brought down the cost of treatment per patient visit from $328 in 2005 to $120 in 2013. At the core of his model are call center employees. These staff members use the existing patient database to make reminder telephone calls and reschedule missed appointments. They follow up with guardians whose children received free, basic dental screenings provided in schools, day care facilities and Head Start centers. This phone call provides Sarrell Dental an opportunity to begin building rapport with guardians and to offer Sarrell Dental’s services if the child does not have a dental provider. If the guardian chooses to use Sarrell Dental services, call center staff will schedule an appointment at a time and location most convenient for the guardian.
Ultimately, call center staff’s primary responsibility is to maximize the daily chair utilization rate in each office. Their ability to maximize the daily chair utilization rates is what affords Sarrell Dental the ability to function as a fully sustainable Medicaid practice. When scheduling appointments, call center staff are trained to take into consideration the typical length of dental procedures as well as the average no-show rates. This approach enables them to balance the number of appointments they think will result in effective utilization rates, while minimizing the potential negative side effects of long patient wait times and overly high patient loads for clinical staff. Call center staff members track and monitor individual patient show rates on a daily, weekly, and monthly basis.
Another unique aspect to Sarrell Dental’s business model is the cost-saving strategy Jeff has employed with regard to working with dental supply representatives. Traditionally, dental practices are established in partnership with a representative from a dental-supplies provider. This relationship soon becomes monopolistic, in that the dentist becomes loyal to their respective representative and supplies offered to that practice are controlled by the rate the representative sets. Jeff saw this as a burden on expenses and has set out to build a different relationship with his representatives. Instead of creating the traditional representative relationship, the Sarrell Dental team works with multiple vendors to find the best rates for Sarrell Dental’s supplies. This strategy significantly saves costs, affording Sarrell Dental to work with Medicaid patients and sustain its business through Medicaid reimbursements.
Within a few years of initiating and refining these strategies, Jeff has established the largest dental practice in Alabama reaching 145,000 patient visits per year with 14 clinics, one dental bus and 262 employees. This growth was not without its challenges. In 2010, with the success of Sarrell Dental across Alabama, traditional dentistry began to take notice and erroneously complained that Sarrell Dental was competing unfairly because as a non-profit it paid low rent, did not pay payroll taxes, and received its supplies at a discount. None of this is granted by the IRS’s 501(c)3 approval. Additionally, it was illegal for a non-dentist to effectively own and operate a dental facility in the state of Alabama even though 501(c)3’s have no owners. After a year of dispute, state legislation passed a bill stating that a 501(c)3 entity registered in Alabama, and therefore a non-dentist, can by law operate a dentistry.
While the road was bumpy for Jeff, he has proven through Sarrell Dental that oral care practices can participate in Medicaid, operate a fully sustainable business and effectively treat millions of currently marginalized children. Jeff is poised to continue this significant growth and to reach his vision of treating every publicly-insured American child. States and the ADA will need to recognize the feasibility of Jeff’s model and embrace non-dentist ownership. Jeff believes that he is on the path to the tipping point, and that once Sarrell Dental has operations in three to four states, the rest of the country will follow. In particular, as the Affordable Care Act introduces millions of newly-insured patients, dentists across the U.S. can learn from Jeff’s innovative strategies and embrace these practices as a means to serve the millions of youth without access to oral health care.
Jeff is working to mitigate the challenge of national perception and policies by sharing his model as much as possible. In 2012, the Robert Wood Johnson Foundation and ICF International completed an in-depth study of Sarrell Dental titled Systematic Screening and Assessment of Workforce Innovations in the Provision of Preventive Oral Health Services wherein they highlight the promising workforce innovations Jeff has established that increase access to and availability of preventive oral health services. Additionally, Jeff welcomes and encourages site visits from practitioners, academics, insurers and others to meet with his team and better understand Sarrell Dental’s practices. Jeff also shared about his model through major dental publications. In December 2013, Jeff became the first person ever from the dental field to be named as a Top 20 Health Leader by Health Leaders magazine. These efforts all aim to create a national conversation that embraces the model Jeff has established in order to both treat the millions of untreated youth as well as create a new industry standard for dental practices to participate in Medicaid and other public insurance programs.
After graduating with an MPA at age 24, Jeff rose quickly through the ranks of numerous consumer packaged goods companies. He excelled at corporate turn-arounds and at age 31, found himself the youngest division president of a Fortune 200 company. By 40 years old, Jeff was poised for retirement, and feeling as though he had “made it”, he took the opportunity to retire from the corporate sector. Soon after, Jeff took on a teaching position at Jacksonville State University as Executive in Residence teaching the capstone courses in both the undergraduate and MBA tracks.
It was during Jeff’s time at Jacksonville State in 2004 that Dr. Sarrell sought Jeff’s advice. After Dr. Sarrell shared the struggles of the clinic and his vision for serving the children of Alabama, Jeff agreed to join the organization and serve as CEO. Jeff shares that while he was always aware of the myriad of challenges indigent people face throughout the U.S., his immersion into Sarrell Dental served as an awakening. He shares the story of Deamonte Driver, a young boy in Maryland who was on Medicaid and could not get oral health treatment. Sadly, Deamonte’s untreated issue resulted in his death. To Jeff, this story shed light on a problem that no child should face in a society with so simple a solution readily at hand. He has made it his mission to solve this problem first in Alabama, and then nationally – so that one day, every child will have access to preventative oral health care.