Discussion on Health System and DSO Collaboration

Randall Roisman discusses the rationale behind creating the first medical-dental integrated practices in an effort to reduce total cost of care.

DSOPro: Tell us about your experience and entre into dentistry.

I have spent over 25 years in the healthcare industry, in both dental and medical services in finance, strategy, and operations in both ambulatory and acute settings. I’ve been fortunate to have had the opportunity to lead teams to really grow organizations. More than 17 years of my career was spent at one of the largest, private practice dental group practices in Southern California.

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Dental Plus Dental Group was a multi-specialty group practice in Pasadena, CA, offering a comprehensive range of services and procedures, including endodontics, periodontics, oral surgery, orthodontics, pediatric dentistry, and cosmetic and restorative procedures for the entire family, as well as various sedation modalities for both children and adults. We were one of the first sites in the state licensed to provide adult oral conscious sedation as a treatment alternative.

The practice’s focus was providing high-quality, affordable dentistry, as well as patient, provider, and staff satisfaction. Dental Plus was a 26-operatory facility, including a surgical suite. Operationally, we were different from many practices, which allowed us to be very efficient. Specialists were onsite multiple times per week versus once or twice per month as in some other offices. As a result, Dental Plus was able to treat 200 patients per day at the one site, with approximately 48,000 visits per year.

I joined Dental Plus in 1996, and eventually became the Chief Financial Officer (CFO). While the practice had strong top-line revenue, there were opportunities for both revenue enhancement and expense control. During my time with Dental Plus, revenue grew over 220%, and profitability improved due to operational efficiencies.

During the late ‘90s, when DSOs were rolling up practices, Dental Plus was a platform practice that many private and public entities sought to acquire. The practice changed ownership in 2012, and I remained on to assist with the transition through late 2013. At that time, I transitioned to the medical side of healthcare.

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DSOPro: Describe that part of your career for us.

In 2013, I joined Cedars-Sinai Medical Network, the physician division (Medical Foundation) of Cedars-Sinai Health System in Los Angeles. The Medical Foundation has Physician Services Agreements, or contracts, with providers in various medical groups and independent physician associations (IPAs) to provide healthcare services to the Foundation’s patients. The Medical Foundation is supported by the health system.

My role at Cedars-Sinai as the Executive Director of Financial Planning, Analysis, and Acquisitions was to acquire and affiliate medical groups, practices, and individual providers to the Medical Network. It was very similar to the mergers and acquisitions that DSOs were making back in the ‘90s, but in this case it was a health system. In Southern California, there was a definite intention by many health systems to acquire groups to help them grow their provider networks to be able to support the growing patient populations.

Later, I was the CFO of Providence Saint John’s Health Center, a 266-bed acute-care hospital in Santa Monica, CA, which is part of the 51-hospital Providence Health System, including 11 hospitals in Southern California. Most recently, I was the CFO of MemorialCare Medical Foundation, the physician enterprise within Memorial Health Services. MemorialCare is a four-hospital health system covering Orange County and southern Los Angeles County.

MemorialCare Medical Foundation includes a medical group with over 350 providers, an IPA with 150 physicians, and contracts with in excess of 2,000 downstream providers. The Medical Foundation also includes five healthcare-related joint ventures.

DSOPro: Were you involved when MemorialCare and Pacific Dental Services decided to launch a joint venture?

Yes, I was very involved in the creation of the joint venture between MemorialCare and Pacific Dental Services to create co-located sites. Having spent many years in a dental practice that was treating so many patients, I had the opportunity to learn about a variety of health conditions. Part of the practice’s standard health history process was understanding the patients’ overall health conditions and the impact that the dental treatment would potentially have on the patients. For procedures involving sedation, for example, when certain health conditions were present, the dentists would seek a consultation with the patient’s medical providers to ensure that the patient was well enough to undergo certain dental procedures. Conversely, if patients were undergoing treatment for cancer, for example, often the oncologists requested confirmation that the patient’s oral health was stable prior to initiating treatment.

All of these interactions and cross-referrals piqued my interest, and I began researching further how oral health impacted systemic health. I learned about the correlations between oral health and diabetes, cardiovascular disease and stroke, various types of cancer, fertility, and more.

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When I transitioned to the medical side of healthcare, I realized that oral health was generally not managed by primary care providers, almost as if the mouth was completely separate and not part of the body, both from a professional standpoint and its delivery system. Medical and dental care historically have been very siloed, and rarely is there regular communication between doctors and dentists.

A recent case study noted that an accountable care organization (ACO) cannot be accountable for a patient’s overall health if it does not address oral health needs. In much of my research, most articles discussed the differences between medical and dental delivery systems. But having worked closely in both spaces, and gaining that unique perspective, I realized there are many similarities. And from a patient’s overall health perspective, I saw a great opportunity to potentially close gaps in care and focus on comprehensive, “whole-person” healthcare. It was then that I presented to my senior management colleagues the opportunities arising from integrating medical and dental care, including an option of co-locating practices in a single site.

From a health system perspective, especially for entities that are risk-bearing organizations and accept capitated payments, it is a way to potentially reduce total cost of care by identifying and addressing health conditions earlier.

DSOPro: Describe the planning and special considerations for bringing everything together between MemorialCare and Pacific Dental.

When looking at opportunities within health systems in general, my colleagues and I evaluate various options for service line expansion. In many health systems, dental care is not routinely part of the service offerings. For organizations looking to expand into dental, considerations would be made regarding service area, as well as investment, personnel, and timing, among others. In this situation, a joint venture was the appropriate option. Based on my past dental experience and network, the team determined that Pacific Dental Services (PDS) was the right partner. PDS already understood the oral-systemic health connection. Together, we constructed a plan for the co-location of medical and dental offices.

Of course, for health systems, there are alternate ways of accomplishing this without partnering with a DSO. In addition, there are multiple other opportunities for a dental group or DSO to work with a medical organization without it being a joint venture. There are multiple ways to solve this, but ultimately by doing what is best for the patient, all of healthcare benefits.

DSOPro: Discuss new technologies that help make this kind of collaboration easier and more successful.

Electronic Medical Records, or EMRs, are one of the best tools for this type of collaboration. In the current example, both the health system and the DSO were on the same platform. So as a result, the dentist can see if their patient has had a vaccine or other preventive care, such as a colonoscopy or a mammogram. If not, they can assist the patient in scheduling an appointment. And if the dental and medical offices are co-located, it can be even easier. From the medical office side, for example, a doctor who is treating a diabetic patient can review the EMR to determine if they are in active periodontal care with their dentist. It is important to integrate these reviews as part of the workflow of the practices. Completing timely preventive care procedures can potentially help identify health conditions earlier, which can mean reduced costs of care for the patient and healthcare overall.

Even if the medical and dental offices are not on the same EMR, there are potential options to bridge the gap. In the end, the goal is to encourage improved communication and collaboration between dental and medical professionals and provide comprehensive healthcare to patients.

DSOPro: Does the insurance sector need to change to accommodate this collaboration?

Yes, there will be many opportunities for both health systems and payors as a result of this type of collaborative care model. Health systems may be better equipped to take on more risk-based contracts if they are able to better manage the patient population via their oral healthcare. Payors also want to manage the costs of care. CMS recently expanded coverage for Medicare to pay for certain dental services when that service is integral to treating a specific medical condition, including head and neck cancers. With this type of collaboration between medical and dental professionals, the opportunity is there to expand coverage and reduce the cost of healthcare. Patients benefit, providers benefit, and payors benefit.

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DSOPro: What type of roles or jobs are created that are different in an integrated model? What kind of talent would a place like that look for?

In order to create a comprehensive integrated model that includes oral health, there should be a core team of people who have the vision and understanding of both dental and medical organizations, including strategy, operations, and clinical. That includes a strategic leader who understands the various business opportunities related to medical and dental integration; an operational leader who can effectively integrate the necessary workflows within both specialties, from the moment the patient is greeted until the time they leave the office; and a physician champion who can collaborate with their physician colleagues and further explain the correlations between oral health and systemic disease, the impact on one another, and the benefits of interdisciplinary collaboration. Currently, there are relatively few teams that possess the combination of medical/dental knowledge, financial expertise, and operational experience necessary for a successful integration.

DSOPro: Do you think this will impact how people regard the importance of dentistry?

Absolutely. I believe overall we are in the early stages of this type of collaboration, and the opportunities are tremendous. Beyond medical school, many physicians do not have ongoing exposure and training in oral healthcare. But healthcare organizations that can break down the historical silos of medical and dental care will be at the forefront. For dental groups or DSOs that are interested in collaborating or partnering with healthcare providers or larger organizations, there are a number of opportunities and options that can lead to their expanded growth as well. Ultimately, this is about providing comprehensive care for patients, and with continued interprofessional and interdisciplinary collaboration, both providers and patients will understand the importance of dentistry and oral health.

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About Randall Roisman and Olive Tree Advisory Group 


Randall Roisman’s  career has spanned more than 25 years in healthcare finance, strategy, and operations, including multiple C-Suite and VP/Executive level roles within various complex and well-respected integrated delivery healthcare systems and large dental groups in one of the most competitive markets in the country – the Los Angeles and Orange County area, including Cedars-Sinai, Providence, and MemorialCare.

Roisman has more than 17 years of experience in the dental industry leading one of the largest private, multi-specialty dental groups in Southern California. Most recently, he was the Chief Financial Officer of MemorialCare Medical Foundation, the physician enterprise within the MemorialCare health system in Southern California. The Foundation included a medical group with more than 350 primary care and specialty providers, an IPA with 150 physicians, and contracts with in excess of 2,000 downstream specialists, as well as five healthcare-related joint ventures.

At MemorialCare, Roisman created and developed a transformative, industry-first joint venture partnership between MemorialCare and Pacific Dental Services, a leading national dental support organization also based in Orange County, to build multiple co-located medical and dental offices in which primary care and dental providers will address the connections between oral and systemic health, provide patients with access to comprehensive healthcare focused on the health of the whole person, and reduce the total costs of care. The joint venture further benefits from the use of the same electronic medical records, which allows providers to share information more easily, creating a more seamless experience for patients.

Randall Roisman is now the Managing Partner of Olive Tree Advisory Group, LLC, a healthcare management consulting group that assists dental and medical organizations – both for-profit and non-profit – with strategy, finance, operations, mergers and acquisitions, and transaction support and solutions, including the creation of the oral-systemic model.

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