Key Questions (+Answers)

Here's a list of key questions that you should consider asking yourself or others as you go through the process of choosing a corporate or large group associateship. By clicking on the "+" sign, you find an answer that has been provided by people that have gone through the same process. 

General Information

There are so many questions that relate to a corporate dental organization. The following information touches on some the most commonly asked questions.

What is the remuneration in corporate dentistry?

Although there may be some flexibility in the way that associate dentists are remunerated in corporate dentistry, most often the compensation is approximately 30-40% of the collected fees.

Is it true that I must have a baseline production in a corporate dentistry environment?
Yes, it may be true that dentists are required to hit certain baselines or targets; however, this usually applies to the owner dentist who has sold his/her practice to a corporate entity and can also depend on the structure of the sale and the negotiations which took place. In some situations, this may be a reflection of the high purchase price which was paid to the owner. Generally speaking, if the owner received a much higher price than the market value of the practice in the open market, he/she will be subject to stipulations and conditions.

For new graduates or associate dentists, typically there is a commitment from the corporation to help the associate become a better dentist and to ensure they can make their student debt loan payments. In some instances, they may be guaranteed a salary (e.g. $120K base salary) if a commitment is made to stay for a certain period of time; however, this varies from entity to entity.

What is the standard remuneration and what does it include (e.g., recall checks, X-rays, etc.)?

This varies based on the contracts that have been negotiated. As an example, an owner dentist who has sold to a large group or corporate entity may have received a higher purchase price in exchange for a smaller percentage fee as an associate. Typically, any associates that the practice had at the time of sale will remain at the same rate of compensation as outlined in the initial contract with the owner dentist.

With respect to recall checks, usually the dentists are paid a percentage of the recall exam fee. Fees for interpreting radiographs taken by the hygienists during a recall examination may or may not be part of the compensation.

Can I buy shares or equity in either a group practice or corporate dental practice?

In some situations, there is an ability to buy both shares and equity. For an owner dentist selling to a corporation, he/she may have the option to obtain shares in the group or the individual dental practice. As an associate, it is unlikely that buying shares at the corporate level is an option. However, it is a changing environment and corporate entities understand their models only work if people choose to work within them and sometimes this involves owning a “piece of the pie.” When shares are offered, they can sometimes act as an incentive, because the shareholder may be more willing to work hard and make sacrifices to earn his/her return-on-investment (ROI).

What are some incentives offered to associates to work for larger dental corporations?

Some of the incentives offered to associates may include but are not limited to:

  • Access to continuing education (CE)
  • Signing bonuses
  • Reducing or lifting the financial burden which allows dentists to focus on providing dentistry and not business

Should you sell to dental corporations?
The answer to this question is unique for every dentist and situation. Most dentists who sell to a corporation want to keep working for a period of time before they retire which is different from previous times where the dentist sold the practice and worked for a specific transition period and then stopped practising dentistry. Corporate dentistry is geared towards those dentists who want to sell and reduce their HR and business involvement in the practice. Transactions are based on the profitability of the clinic and many may involve partnerships of some form.

Who are some of the large dental corporations operating in Canada?

  • Dental Corp >300 clinics
  • Altima 50-80 clinics (mix medical/dental together)
  • 123 Dentist ~135 clinics (60 partnership and 70 in corporate model)

Large Group Practice

While corporate dentistry organization may look or feel similar to large group practices, there are some fundamental differences. The following information loosely defines a “large group practice.”

What defines a “large group practice”?
Many people consider large group practices to be ownership of between 5–10 clinics. For more than 10 clinics, it is difficult for a dentist to manage them well alone. Another definition may include a practice in one location with multiple dentists and/or specialists.

What are the pros/cons of a large group practice?
Multiple group practices owned by a dentist(s) are usually purchased using personal equity. After a certain threshold, banks may be reluctant to lend funds to purchase more practices. At this point, private equity is usually used as one can obtain better and faster growth using this type of funding.

Mentor Advice

The following responses come from our pool of experts who were consulted and interviewed as they relate to both corporate dentistry and large group practices.

Is there a bonus structure for ‘producing’ a certain amount of revenues per month? (This may be an ethical concern because treatment being prescribed may not be necessarily part of a patients’ well-being?)

With respect to ethical concerns and bonus structures, the ethics are dentist-specific and not related to the bonus/quota structure which may be in place. In fact, it is more likely for corporate and large group entities to be scrutinized more carefully with respect to their operations and as such, these entities are very aware and sensitive to “overtreatment” issues.

When it comes to bonus structures, typically anything produced over a certain baseline would be incentivized in some way. The bonus may be individual-specific or team-specific and again, varies from practice to practice.

With respect to ethical concerns and bonus structures, the ethics are dentist-specific and not related to the bonus/quota structure which may be in place. In fact, it is more likely for corporate and large group entities to be scrutinized more carefully with respect to their operations and as such, these entities are very aware and sensitive to “overtreatment” issues.

When it comes to bonus structures, typically anything produced over a certain baseline would be incentivized in some way. The bonus may be individual-specific or team-specific and again, varies from practice to practice.

Are there billing or treatment quotas that I must reach in a month?
Again, this depends largely on the arrangement that has been negotiated and what is outlined in the contract. Some corporate entities prefer not to push people to work for targets. Every corporate or group practice will have a different philosophy.

Volume-based treatment does exist. As an example, some orthodontists are encouraged to do a certain number of Invisalign cases in a period of time and are then given a rebate.

Keep in mind that dental regulators generally take a dim view of billing/treatment quotas and targets that put corporate profits ahead of patient-centred care. As the clinician, the dentist is ultimately held responsible by the regulator for the care provided, not the corporation.

Who do I talk to about any clinical concerns I have with my patient or if I need some guidance?
In any group practice, there will be specialists and/or mentors who will be able to give other colleagues opinions or guidance, as required. In addition, in-house continuing education (CE) opportunities or study clubs may also exist. In some corporate structures, a Chief Dental Officer may take on this responsibility or be responsible if bigger issues arise.

As always, peer support can also be sought from colleagues elsewhere including local component dental societies.

In a group or corporate practice, do I have to use all the systems and materials that they use?
Typically, if a partner or owner has a system of what they use, then associates are expected to use the same systems or materials. This is usually decided at the partner level and new dentists will not be given the freedom to choose whatever they want. In cases where the associate is quite seasoned, there may be a little more freedom to choose but, even then it will be limited. Usually, associates will have a little more choice when it comes to endodontic systems and they will be encouraged to purchase their own. Most often, however, a practice that has been sold to a corporate entity will likely experience few changes or disruptions with respect to day-to-day operation including the choice of materials.

Will there be a buy-in opportunity?
Buy-in opportunities will differ among corporate entities. Some corporations may provide opportunities to buy-in at the clinic level, but it is unlikely that there will be an opportunity to buy shares of the corporation.

How will new patients be allocated between the various dentists?

This will differ from practice to practice; however, it is likely that the schedule with a “hole” will get filled with the new patient unless the new patient has requested a specific dentist. Early career dentists are more likely to have new patients allocated to their schedule to help build their patient base and become better known in the practice’s community.

Are associates allowed to refer to any specialist of their choice, or do they have to refer in-house?
From a patient care perspective, it is preferable to refer within the practice as patients are often more likely to make and attend their specialist’s appointment. In some cases, corporations also own specialty practices and will encourage referral to those specialists or have the specialist work in the general practice setting to see patients on predetermined days and times. Most of the time, however, specialist referral is not mandated.

In some provinces, the dentist may be required to disclose any conflict of interests or financial interests he/she may have when referring patients to a particular clinic(s).

If dentists share patients and one decides to change the treatment set out by another dentist, how does this translate to the patient?
This is an ongoing clinical practice issue. For example, at times, a new dentist may not see the same issues that may be present as a more experienced dentist. These are complicated situations, but in the end the continuity of care and best possible care are central to the issue.

In a group practice, it’s important that the dentists/team are aligned with respect to treatment philosophy to avoid these scenarios. As far as possible, the goal is to try to keep complicated treatment plans with the same dentists and not to move patients from dentist to dentist. At times, if the patient can only attend at a certain time of day, the patient may be seen occasionally by another dentist for a more routine aspect of their care (e.g. simple filling).

However, when a situation like the above does occur, it is imperative that there is an open discussion with the patient about why there may be a change in the treatment plan and how that may affect him/her and the cost of treatment. Ultimately, it is the dentists’ responsibility to ensure that our patients receive the best care.

What is the protocol for discussing failed treatment with patients when it’s done by another dentist at the practice?
In these situations, the office manager and/or owner usually get involved to resolve the matter. If the treatment was performed within office, it is redone and paid for by the office, if it is not deemed to be a patient-related issue. However, in reality, the patient rarely takes personal accountability for the issue. To avoid these issues and maintain the reputation of the business, the office will usually address the matter.

As long as the dentists have the experience and training to perform a procedure, they will be permitted to practice within their scopes. In reality, however, sometimes what an associate believes he/she can do is different from what they can do comfortably and reasonably from a patient care perspective.

At times, staff may voice a concern to the owner(s) to ensure that optimal patient care is provided at all times. In this way, a culture of openness is paramount to having good patient outcomes.

Can associates choose to use any lab?
It is preferable for the associate to use a laboratory that has an established relationship with the office/owner. This will ensure consistency with laboratory use. But, more importantly, if the associate leaves and a crown needs to be remade, for example, the lab is more likely to help correct the matter at minimal or no cost. It is more difficult in a situation where the owner dentist/office does not use the same laboratory as the associate.

Typically, however, laboratory use is not dictated at a corporate level but more on a local level.

Are patients assigned to a specific dentist for their ongoing care or will they just see whichever dentist is available on the day/time they come in?

Continuity of care for patients is important. As such, wherever possible, patients will see their assigned dentist. In an emergency, where the usual dentist may not be available or working, the patient may be given the choice to see another dentist.

Will my treatment plans be reviewed by another dentist?
This will depend on the policies of each corporation or office. If there are concerns about the treatment plan, the dentist(s) may confer among themselves to discuss the best possible treatment for the patient.

How is vacation time, CE or time off dealt with (are there minimum or maximum days allowed)?
As far as vacation time goes, up to 4 weeks may be granted. Veteran dentists may be permitted to take time off as needed. But if vacation schedules coincide, seniority will likely preside at a group practice. Some early career dentists don’t use all their vacation time as they may want the extra hours to help pay down debt loads.

Will dentists share the long weekends? Share evenings?
In general, the dentist with the lowest seniority or experience will likely have the seemingly “worst” hours. In many cases, early career dentists may not have spouses or children yet, so they will be given these hours. In addition, people booking evening and weekend appointments usually do not have a preference of which dentist they will see so this can also work to the associate’s advantage and help fill an otherwise potentially empty schedule.

Who will be the emergency phone number on the office answering machine?
This varies from practice to practice. At times, the emergency number may be a 24-hour central line, the associate or main dentist’s cell phones. Emergency duty may be shared and rotated among offices or whatever is deemed to be reasonable.

Do I need to sign a contract?

Yes, it is always recommended that the contract is read and reviewed by a lawyer. The contract is meant to protect the corporation and the business. If while working as an associate in a traditional practice, the practice is sold to a corporate entity, it is in the associate’s best interest to avoid signing a new contract on the spot. Instead, seek the advice of a knowledgeable and experienced lawyer.

What are the primary elements of the associateship contract within an organization?
The primary elements of the associateship contract include compensation (percentage and any other elements), non-competition and non-solicitation clauses and the cost of any charts that are “stolen”. The non-competition clauses in some situations may state that the dentist upon departure may not work a certain distance from any of the corporation’s location not just the practice that he/she provided patient care.

Typically, corporate entities tend to have longer and more detailed contracts with stiff penalties built in for any associate that leaves a practice and takes patients or existing staff members upon departure. At times, these contracts may be intimidating for young or less experienced dentists.

If provisions are broken by a departing associate, a traditional solo practitioner may not seek damages. This may not be the case in the case of corporate dentistry where the power imbalance lies with the corporation from the outset.

As a potential vendor, to meet with the corporate entities initially may involve signing lengthy non-disclosure agreements.

How many new patients does the clinic get per month?
This is good information to know before accepting a position as this will help determine whether the schedules can be filled easily or not. The number of new patients will vary from office to office, city to city and also depend on the physical location of the practice. Many other factors such as marketing efforts will also impact the number of new patients the clinic draws. Some corporations will focus on buying only ground floor retail locations which have easy accessibility and visibility and may attract 20-90 new patients, monthly.

Will associates have to help pay for marketing or staff or equipment?

Generally, associates are not expected to pay for marketing, staff or equipment. However, for specific procedures or systems like endodontics or implants, it is preferable for the associate to have his/her own system and in the event that he/she leaves, it can be taken by the associate. With respect to compensation in such cases, the associate may receive a higher percentage of the fee to account for the fact that he/she has paid for the materials/equipment.

Although the formal marketing is provided by the corporate or overarching structure, it is helpful for the associate to market him/herself by asking for referrals, handing out business cards and/or establishing a rapport within the community. It is inadvisable for a new associate to become dependent on the practice to do all the marketing “work” to fill his/her schedule.

Should I be asking if this is a new position or if I’m replacing previous associate?

This is good to know as it can give insight into what previous expectations there were for the associate or whether this is a new position and establishing new parameters etc. If possible, it would be a good idea to speak with the previous associate(s) and ask questions of the practice before accepting the position. The number of previous associates that have come and gone from the office may also provide valuable information.

Is the practice owned by a corporation?
This is also a valid question to ask and may affect an associate’s decision to accept or reject the position. If the associate intends to buy-in at a future time, it should be outlined clearly in the contract.

It is important to understand that “corporation” is a complex word when associated with dentistry. For tax purposes, many individual dentists as practice owners incorporate and have, therefore, created a corporation. This is not the same as a “big box” dental corporation that owns a string of dental practices across a wide geographic area.

Is the practice considering purchasing or opening other locations?

While the information may not be available or even under consideration, again, this will allow the associate to test out options for some sort of partnership in the future.

Is there a restrictive covenant? How big is it? How long is it valid?
The restrictive covenant can be anywhere from 1-2km -15km depending on the location of the practice. Additionally, the radius of a restrictive covenant tends to be larger with corporate entities and the potential associate should know if they must respect a “no set-up” distance from only the location where they practiced, or from each location within the corporate network.

Will I be involved or will my opinion be consulted on hiring/firing/reviewing staff that I work directly with (i.e. my assistant)?
Generally speaking, the associate may have some input on the hiring of a dental assistant. However, the reality is that currently there is a shortage of staff members in many areas in Canada, so there’s not as much competition or choice in the dental marketplace.

What has the staff or associate turn over been like? Have the current staff been there long term?

Staff turnover can vary as each practice will have its own qualities. In some offices where the main dentist may be more “unique”, there may be more turnover. However, in general, the aim is to have consistent, long-term staff who are close to their homes.

Is there mentorship available? Both in dentistry and the business side of the practice?

Ideally, most owner dentists would like to act as a mentor, but sometimes the limiting factors including the associate and principal schedules do not coordinate. In this situation, it will be the associate’s responsibility to ensure that he/she makes time for the mentoring. It may even mean coming into the office on a day-off or before or after a shift. Some corporate entities offer in-house learning opportunities for dentists with systems and tips that have been proven to help more inexperienced dentists.