A joint investigation with

Patients, Pressure and Profits at Aspen Dental

by Center for Public Integrity, and Jill Rosenbaum, FRONTLINE

Surviving on a meager $1,300 a month, 87-year-old Theresa Ferritto fretted about the cost when her dentist told her she needed two teeth pulled.

She figured an oral surgeon would be too expensive. So she decided to try out a dental chain that promoted steep discounts in its advertisements. She went to an Aspen Dental office just outside Cleveland.

Ferritto said Aspen Dental wouldn’t just pull the teeth but insisted on a complete exam. She was bewildered when they finally handed her a treatment plan four pages long. Total price: $7,835.

Ferritto could not afford it, but Aspen Dental signed her up for a special credit card, with monthly payments of $186 for five years. She blames herself for signing the papers.

“I made a big mistake going there,” she says. “I should have known better.”

After a day of cleanings and two fillings, Ferritto asked her son for help. He called Aspen Dental to complain but said he got nowhere. So they turned to the state attorney general.

Aspen Dental took all charges off her credit card for treatments she hadn’t yet received. But the company said the $2,540 she was charged for two fillings and cleanings was appropriate.

Aspen Dental charged Ferritto $350 for an antibiotic put next to teeth the dentist was going to pull, a charge other dentists say makes no sense.  There were four separate charges for an antibacterial rinse, similar to Listerine, for $129. There was even a $149 charge for an electric toothbrush that Ferritto didn’t even know she had, until she recently retrieved an Aspen Dental bag from her garage and found it inside.

Imagine how many groceries that would buy, she sighed.

When asked if Ferritto was taken advantage of, Aspen Dental chief executive Robert Fontana said, “I hope that the team was clear about what she needed and that that she completely understood what she was getting into.  And hopefully, you know, she made the choices that she thought was right for her.”

Aspen Dental is a chain of nearly 350 offices in 22 states managed by a company owned by a private-equity firm. It is part of a fast-growing industry of corporate dental practices, many of which specialize in serving people who cannot afford to go to the dentist, a group many dentists ignore.

By marketing to people who haven’t seen a dentist in years, Aspen Dental often gives new patients treatment plans costing thousands of dollars. The Center for Public Integrity (CPI) and FRONTLINE spent months examining Aspen Dental and found that the same business model that makes Aspen Dental accessible to people short on cash can also lock people into debt and has led to complaints of patients being overcharged or given unnecessary treatments.

Former employees say Aspen Dental trained them in high-pressure sales. Corporate management scrutinizes the production of dentists and staff daily. And internal documents show that dentists get paid bonuses as key production targets are met.

“You’ve got people who are not dentists, that are in management… they are breathing down the doctor’s back,” said Jenny Hayes, who worked as an office manager for Aspen Dental in the Chicago-area last year. “There are goals and if you are not hitting your goals, then you lose your job.”

Aspen Dental denies that its dentists have stronger financial incentives than other dentists or that its bonuses affect treatments. Fontana, founder and chief executive officer of Aspen Dental, based in East Syracuse, NY, said dentists won’t do unnecessary treatments because “it’s just not in their DNA.”

“I’m not even sure what corporate dentistry means, because we have no influence on the dentistry,” Fontana said.

He said Aspen Dental frees dentists to focus solely on patients, because the company handles back-office duties such as marketing, accounting and billing. In fact, dentists own and control all of the practices, says Fontana. All but four states forbid anyone who’s not a dentist from owning a practice on the assumption that dentists are trained and motivated to put patients ahead of profits.

But Sen. Charles Grassley, a Republican from Iowa, questions whether dentists at corporate dental chains are free from corporate pressures to maximize profits. Grassley, the ranking member of the Senate Finance Committee, wouldn’t speak about Aspen Dental specifically, but he’s had committee investigators looking into the company and other private-equity-owned chains for months.

“Because when private equity firms get involved,” Grassley explained, “you got to understand that their motivation is to make money. And they are not dentists.  And dentists ought to make the determination … of what is good for the teeth… Not some private equity manager in Wall Street.”

Aspen Dental says it serves people who otherwise wouldn’t go to a dentist. Forty percent of Americans have a family member who put off going to the dentist because they couldn’t pay for it, according to a survey by the W.K. Kellogg Foundation. Fontana says Aspen Dental looks for ways to make it easier for those people to walk into their offices.

Their offices are easy to spot at shopping centers, often near fast-food restaurants. Posters advertise a free exam and X-rays. Many of their new patients walk in the door without an appointment. Aspen Dental accepts most insurance and if the patient is still short on cash, they will sign you up on your first day for “no-interest” credit cards through GE Capital or Chase.

Aspen Dental specializes in dentures, which they make in each office. The consultation room has a tray of dentures to choose from, ranging from the basic no-frills model to the “precision hand-crafted” ComfiLytes, coming in 27 shades. Internet ads offer dentures on sale for $249. Its commercial tells stories of a man in pain from poor-fitting dentures and a woman too embarrassed to smile.

Aspen Dental insists that all new patients get a comprehensive examination. So even if someone just wants a routine cleaning or needs a broken tooth fix, Aspen Dental presents a treatment plan for any problems that may crop up years later. Fontana says this approach is what’s best for patients, because neglected teeth and gums can lead to serious problems. Several former employees, however, describe the initial exam as a sales tactic to maximize revenue on each new patient.

“People would come into the office maybe with a toothache and come out with a treatment plan that maybe the dentist said we need to extract all your teeth,” said Jenny Hayes, the former office manager in Illinois. “They were made to stop in the manager’s office and sit down for an intense consultative selling process that they really didn’t bargain for when they walked in the door. I had people literally breaking down and crying in my office. And it happened quite regularly.”

The average treatment plan presented to new patients runs $4,450 at Aspen Dental’s top producing offices, according to an internal company document obtained by CPI and FRONTLINE. The company says the extensive treatment is a reflection of the patients they draw.

“A typical patient is probably 45 to 65 and struggling just to make ends meet,” said Fontana, Aspen’s CEO. “They’re taking this week’s paycheck to pay last month’s mortgage, making their car payment, trying to put their kids through school and unfortunately, dentistry can become discretionary.”

Donna Kelce of Des Moines, Iowa, fits the profile. At age 55, she hadn’t been to a dentist in 15 years. She didn’t have dental insurance and didn’t think she could afford it. Besides, her teeth never bothered her until a gap starting forming between two front teeth. Embarrassed, she finally went to an Aspen Dental office after seeing one of its commercials.

Kelce was X-rayed and sent to a consultation room, where a dental assistant handed her a treatment plan. Kelce’s gaze stopped on a particular word.

“I could feel the kind of blood run from my face, thinking, “Oh my God. Dentures,” Kelce said.

Kelce recalls the dentist saying she had no real option but to get dentures because she had lost too much bone for implants. She wasn’t sure how she could afford Aspen Dental’s $3,700 bill. But then the office manager signed her up for a “no-interest” credit card through Chase. Relieved, Kelce thought she was getting a bargain.

She came back in late November 2009 to have 13 teeth pulled. But she said the dentist pulled and pulled and couldn’t get all the teeth out, breaking one at the root. Kelce wondered if so much bone was gone, why the teeth weren’t coming out easily. After three hours, the dentist still had six teeth to pull but said she could do no more because she had already given Kelce the maximum dose of Novocain.

Aspen Dental sent Kelce to one of its former dentists who could see her that evening. Dr. Jessica Lawson looked at Kelce’s teeth and concluded that they didn’t all need to be pulled. But she finished the work so Kelce could wear her dentures. She suggested that Kelce report the incident to the Iowa Dental Board. Lawson herself wrote a letter to the board.

“Having worked at Aspen Dental myself for a short period of time, I am well aware of the type of care that can potentiate, especially if the doctor isn’t firm with the office manager and regional managers in providing the standard of care that he/she is use to, instead of producing the numbers that Aspen requests and expects,” Lawson wrote.

The dentist at Aspen Dental, did not return phone calls for comment. But she gave a different account of Kelce’s treatment in her notes. She said she suggested alternatives but that Kelce “insisted on dentures and full upper extractions even though (six upper teeth) can be saved.” She added that four of those teeth might not last forever.

Kelce, who is now suing for malpractice, said the dentist never told her any of her teeth could be saved.

“Who in their right mind would let them pull my teeth if they didn’t need to?” she asked.

Dr. Gerald Marlin, a Washington DC prosthodontist who specializes in replacing teeth, looked at Kelce’s X-rays at the request of CPI and FRONTLINE. He drew a red line along the bone and said Kelce had plenty of bone to save seven of her upper teeth.

Marlin came up with seven treatment options for Kelce, in most cases replacing her teeth with a bridge or partial denture. He said dentures should only be a last resort. They don’t adhere well and affect a person’s ability to speak and eat. Partial dentures are not only cheaper but they fit securely, anchored by the remaining teeth.

The dental board dropped the case and won’t discuss it, citing confidentiality laws. Coincidentally, that same month the dental board issued a press release, saying, “The Board has seen an increase in complaints in connection with corporate dental practices. The types of complaints include both continuity of care issues and issues related to the business aspects of the practice.”

Corporate dental chains are barely regulated in most states, especially if they don’t accept Medicaid patients. State dental boards typically don’t have any power over corporations.

Lili Reitz, executive director of the Ohio State Dental Board, said last year a quarter of her complaints – or 140 – were against dentists at corporate chains. Yet she has little authority to take action against the companies. Instead, her power comes from having control over the license of individual dentists.

It’s common for Reitz to get complaints that private dentists are trying to do unnecessary care, such as putting fillings on cavities that other dentists don’t see. Still, Reitz says the pressures on dentists at corporate dental practices seem more intense.

“I think quotas and how many patients need to be seen a day definitely have an adverse effect on the quality of care,” Reitz said. “What’s frustrating for us is to go dentist by dentist by dentist. By the time we get there, they’re not there anymore” because corporate chains have high turnover rates.

Reitz says dentists tend to stop doing needless treatments after leaving a corporate dental chain, so she considers the problem solved and takes no formal action.

State attorneys general can take action under consumer laws if a dental chain deceives patients. The Pennsylvania Attorney General sued Aspen Dental in 2010, alleging that Aspen Dental advertises “free” exams but still charges patients with insurance. The state also alleged that Aspen Dental failed to reveal that the “no-interest” credit cards it pushes have steep penalties – 29.9 percent interest on the entire amount of the original loan — if a patient misses payments. Aspen Dental settled, paying $175,000 in restitution without admitting wrongdoing.

Dental malpractice cases are relatively rare, attorneys say, because they are expensive to pursue and usually don’t offer big payouts.

Consumer sites on the Internet are full of complaints about Aspen Dental. Fontana acknowledges that the company counted 1,000 complaints posted from 2006 to 2010. But he said Aspen Dental treats 12,000 patients a day, so the number of complaints is relatively small. Aspen Dental has an employee who now responds to the complaints.

Two former dentists at Aspen Dental said Donna Kelce’s story is not surprising. Neither would allow their names to be used because they’d signed confidentiality agreements and feared being sued. But one admitted that he himself pulled teeth that he didn’t think needed to be pulled. It would happen when another Aspen dentist had written the treatment plan and said the patient had insisted on dentures.

He recently left Aspen Dental, saying, “I couldn’t do it anymore…They spend most of their time trying to talk people out of their teeth.”

Fontana dismissed complaints by former employees, saying all companies have disgruntled workers.

Aspen Dental is a pioneer among corporate dental chains. Fontana considered becoming a dentist when he graduated business school in 1991, but decided instead to apply his business knowledge from working in a group dental practice, imagining ways of tapping into the market of people who never go to a dentist.

In 1998, he founded Aspen Dental Management. After five years, the company had opened 50 offices and drawn the interest of private-equity firms. Capital Resources Partners of Boston invested $18.7 million in Aspen Dental in 2004.  The Los Angeles firm Leonard Green & Associates bought the company in 2010 for just under $550 million.

Fontana says private-equity firms want out of a business after about five years, and the key to a big payoff is growth. Aspen Dental opens a new office nearly every week, creating a drag on profits, according to a recent report by Moody’s. Last year, the company made more than $500 million in revenue but had a pretax profit of only $12 million.

The company meticulously tracks revenue targets for each office. Yet Fontana said those targets don’t apply to dentists.

“I think it’s important to keep in mind again, that the dentists don’t have these goals,” he said. “They just don’t have them. They don’t exist.”

But even an Aspen Dental video on the company’s Web site recruits dentists by saying, “Compensation for associate dentists includes an annual salary plus bonus opportunity that increases as key targets are met.”

The video even gives a glimpse of the revenue targets for an office in Springfield, Mass. A multicolored spreadsheet titled “My Practice Metrics” shows that “dentistry” billings for November 2009 were 243 percent above “budget.” The image shows there are also revenue targets for cleanings and dentures.

The scrutiny dentists are under at Aspen Dental is clear in a report that Fontana called the “game tape.” It’s a monthly performance measure sent to office managers. CPI and FRONTLINE obtained one of these confidential reports for an office in Owensboro, Ky. It shows that in February, the office had billed $270,000 so far this year, $35,000 above its target.

The document shows that Aspen Dental also scrutinizes the billings of its dentists. The lead dentist in Owensboro was billing an average of $5,206 a day, earning him praise from the regional director, who wrote “Showing great trends for this month.” But the tape also compared the dentist to top producing dentists, and in that regard, he fell nearly $1,000 short each day.

Heather Haynes, who managed an Aspen Dental office in Joliet, Ill., said that office managers who didn’t hit their targets consistently were likely to be fired. She said that’s in fact what happened to her. Haynes said dentists and hygienists, the office’s revenue makers, faced the same pressures.

Aspen Dental invited CPI and FRONTLINE to a new office in Warsaw, Ind., to show how badly needed its services are. Warsaw, a town of about 13,500, has only six private dentists. Aspen Dental opened an office there after a dentist noticed how many people from Warsaw were driving an hour to Fort Wayne for dental appointments.

Ted Collins, a 47-year-old truck driver, walked into the office that day with an excruciating toothache.“I have to use ice packs at times to keep it frozen so I can get some sleep,” Collins said.

He hadn’t been to a dentist in 10 years and came in because of the free X-rays. Two of his teeth were abscessed, an infection can spread and in rare cases even become fatal. The office gave him a comprehensive exam and found he needed dentures.

Dr. Kurt Losier, the owner of the practice, wiggled several of Collins teeth and showed on the X-ray that his bone had receded dramatically. Losier suggested Collins get the dentures with the longest warranty, which are also the most expensive dentures. Collins couldn’t afford the treatment plan, which came to $7,000. So the office manager tried to sign him up for a credit card. He was rejected.

Patients at Aspen Dental are turned away every day because they cannot afford the treatment, Losier said. To avoid that, the office will trim the treatment plan down. But even that often doesn’t work.

Losier vowed no matter what, he would take care of Collins’ abscessed teeth. Ultimately Collins said a friend gave him the money for the dentures.

Haynes, the former office manager, said she lost sleep at night worried about whether the sales tactics Aspen Dental taught her were ethical. She said she trusted the dentists she worked with. But she was so skeptical of the expensive deep-cleanings sold to so many patients that she herself refused to get one after she was examined in her own office.

Lance Dykes, who managed an office in in Tennessee, said he felt like he was being forced to take advantage of people by selling them treatments he suspected they didn’t really need. He finally quit one day when he says he had to sell a $12,000 treatment plan to an elderly couple who seemed confused.

Dykes said the man looked him in the eye and asked if he had to decide right then. Dykes said no. Go home and think about it. This broke the rules taught in training for closing the deal, which he says, include getting the patient to commit before they walk out.

In December 2008, Sarah Keckler went to an Aspen Dental in Mechanicsburg, Penn., just to get her teeth cleaned. After a long wait, the dentist said the 20-year-old had three cavities and also needed to have her wisdom teeth pulled. She also said Keckler might have oral cancer.

Keckler, who now lives near Washington D.C., recalls the woman talking so loudly that it seemed the whole office could hear. “She was giving this massive disaster scenario. I didn’t believe a thing that she said.”

Keckler went to her dentist regularly, the last time just six months earlier. But a change in her insurance forced her to switch dentists. As she was wondering how she was going to get out of this, the office manager handed her an estimated bill for a little more than $600. Keckler said the manager encouraged her to sign and even to enroll for a special credit card to pay for it all up front.

Angered by what she considered a hard sell, Keckler got up and left and went back to her family dentist. He found no cavities, no need to pull her wisdom teeth and no oral cancer.

Aspen Dental reviewed Keckler’s files and says she was appropriately diagnosed and that other dentists would agree. However, in an interview, Aspen Dental’s Arwinder Judge, the vice president of clinical support, acknowledged that the surface cavities don’t show up in Keckler’s X-rays. The company is relying on the dentist’s notes to support its diagnosis.

Last February, Dr. David Schneider, a dentist in Chevy Chase, Md., examined Keckler and her X-rays at the request of CPI and FRONTLINE. He said there were no cavities, no need to pull her wisdom teeth and no signs of oral cancer.

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