DSOPro: Let’s discuss your background and how you’re helping dentists decide what to do next when they retire.
At the age of 72, I found myself in a situation many of my late-age dental clients were in. They had either initially sold their practices to DSOs and were ready for the final cash out, or they sold to an associate or another dentist. Little did they know what they would encounter after 2 or 3 years of retirement. This was a journey I was about to embark on as well.
There is a certain Western cultural context about late aging that diminishes, depresses, isolates, marginalizes, and discounts older people. They were stepping right into that. I knew this on a personal level. But given my background in transformation, existentialism, and metaphysics, I was able to apply these skillsets to my aging. I could focus on how to age in a way not determined by our Western culture—a culture that is a horrible culture in which to grow old.
There is another thread here. Over the last 20 years, I have spent time with Aboriginal and Native American elders. I have had direct experiences with elders, which opened a channel to my higher wisdom. I saw how elders were in life and what life provided when you’re an elder—that inner peace, that sageness, that equanimity.
There was a certain way I was when I was with them. Other things not available in our culture became available to me inside these relationships. There was veneration, honor, respect, and spiritual regard.
I saw being an elder as a different road to aging for myself and my aging clients: dentists, physicians, executives, and board directors.
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But for dentists who are either approaching late age from late middle age or are already at late age, they need to understand the path to becoming an elder takes study, training, and practice.
“Elder” is not just a normal progression. I found it for myself, and now, over the last 2 years, others at the institute have found it a worthy route that brings a wealth of benefits and a new, fulfilling future.
DSOPro: That sounds fascinating!
Being an elder is fascinating. That’s exactly what I have discovered. I understood eldership at the root level—mentally, existentially, and metaphysically. I understood and experienced eldership at a level where I could personify it in myself.
As an elder, I noticed changes in myself. What became available was inner peace, a higher purpose, equanimity with others, and letting go of my past and required identity. I was on a totally different road now in my late aging. I had a new opportunity available as an elder, not one dictated by the culture.
Another point was that as an elder, you can’t help but see and now really feel our world’s division, distrust, and hate. Whatever conversations people are having with each other seems to be the problem. But what is also obvious to me is that elders are totally absent in these conversations. I say that if an authentic elder were present in these conversations, things would turn out differently.
You see, elders have higher wisdom, which is unavailable in these conversations now. An elder’s presence would change the nature of these conversations, so the mission became clear. Not only does becoming an elder change how you age in many beneficial ways, but it can also influence how the world turns out – a noble mission.
When you become an elder, you inherit a rich and centuries-old legacy. Part of that legacy is trying to heal the world you are in – community, cohort, or tribe. That is what I saw as an elder for our times: a contemporary elder, someone who can make a real difference.
Elder is good for the soul and good for the planet.
At the institute, 40% of our members are dentists.
DSOPro: Do you want to talk about being a dentist?
My dental career began at age 21. It was 1966 when I started at the Maurice H. Kornberg School of Dentistry at Temple University. Then I went on for graduate training and residency in periodontics in Seattle, an advanced degree in immunology at the University of Washington, became a periodontist in the U.S. Air Force, opened a private practice in Bellevue, Washington, became a practice management consultant, a partnered and group practice consultant, and then an industry consultant. Clients included dentists, banks, investors, senior executives of vendors, third parties, and professional organizations.
Finally, as an entrepreneur, I created the DEO, Dental Entrepreneur Organization, and sold it to Jake Puhl in 2017-2018.
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That’s my 58-year career in dentistry and the dental industry. I was trained as a dentist, and this training and development were extremely valuable because it takes one to know one.
There were only 183 attendees at the first DEO conference I held on DSOs, and Rick Workman was kind enough to be my keynote speaker. This was the first meeting ever for dentists in private practice and small groups to learn about DSOs. At that time, to most of dentistry, DSOs were the arch enemies, the destroyers of private practice.
Years later, when I walked into a DEO conference and saw over 800 people, I felt my legacy was complete and that I was done. I knew my time to leave had come. I was probably in my early 70s, and thought Jake was doing a great job, and that I had no place in the company anymore. Emeritus status does thrive in a for-profit ecosystem.
One of the things that happens in retirement is people, including myself, have what I call the “honeymoon holiday experience.” They think, “Oh man, I’m finally done! I’ll play golf and see the grandkids, go fishing, travel, and not set the alarm.” A retirement bucket list of sorts. Well, in my experience, that lasts about 16 to 18 months and then the whole aging reality descends.
After working on myself and with others during this post-honeymoon holiday phase, you can expect some level of despondency, a dusting of despair, and a touch of depression. For some, they realize they are purposeless. For 40 years, your life was on purpose. Now that is gone. You are no longer someone who fulfilled that commercial and clinical purpose. And you realize you can’t have that kind of purpose anymore. Wake up—you’re outdated, and the culture considers you obsolete.
Many retirees try volunteer work or other forms of committee work for a while, but for some, it doesn’t scratch the itch. They need a bigger challenge, and for some, like me, they need a higher purpose.
DSOPro: Is this true for other professional groups like doctors and nurses?
Yes. It’s true throughout our culture. When you get old in our culture, you get banished and eventually warehoused. Our culture is about new, better, and different. We spend $12 billion a year on cosmetic procedures – what does that say about the culture’s attitude about getting old? Watch TV. How is late age represented? The attitudes, prejudices, and stereotypes of getting old are baked into the system.
But for an elder, the game is not what everybody else in the culture is playing; an elder’s game is much different. Their game, my game, is about gaining higher wisdom. And then hanging around people who are playing the same game.
If you’ve been doing something for a long time and know a person will make a mistake if they keep it up, that’s called conventional wisdom. But higher wisdom is not conventional wisdom.
DSOPro: What is higher wisdom?
What I consider “higher wisdom” to be is an advanced understanding or insight that transcends ordinary knowledge and experience. It gives me deep comprehension and sound judgment. It allows me to see beyond my immediate concerns and understand the broader context and long-term implications. I can reach further into the past and further into the future to see the whole picture.
Higher wisdom cannot be taught, and knowledge can’t be converted into wisdom. It lives inside. It already exists but is concealed. The work of an elder is “unconcealing.”
DSOPro: How did you get into the DSO business?
During the ‘90s, I worked as an independent contractor for a healthcare consulting group, The Clarion Group. They wanted someone to work with their hospitals’ physician groups. I kept my hand in dentistry because it was home for me, but it was less than 20% of my practice at the time. From the late ‘90s to the early 2000s, 90% of my clients were major hospital systems and their executive teams, investors, boards, and directors.
This part of my consulting practice exploded. However, when managed care came along, when Medicare became the baseline, no one had any money and consultants were the first ones to go on any budget. I lost everything within 3 months of being on that side of healthcare.
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At that point, DSOs were about 3% to 4% of the dental market. Rick Workman and Steve Thorne where the top of a very short list. At the time, the Association of Dental Support Organizations (ADSO) was comprised of just the board, a bunch of guys who got together to support each other in what they were all trying to do.
But I saw the foreshadowing. I saw mergers and consolidation at every level of healthcare—hospitals, physician groups, nurses. I was in the middle of this change. Dentistry is always a laggard, but it would definitely happen in dentistry as well.
In 2012, Delta Dental Washington had just eliminated their premier plan, which was close to the fee-for-service, and pushed everyone into their PPO plan, which shaved off about 15% to 20% of what everyone had been making. Many Pierce County dentists lost 20% of their revenue in one fell swoop. They invited me to speak at their next annual meeting and when I said that by 2030, more than 80% of dentistry would likely be delivered by DSOs, there were many unhappy and angry faces in the audience. That day, I didn’t win many friends or fans.
But it was obvious to me I was ahead of the curve, and building a business to help the dental industry make this transition was an entrepreneur’s opportunity, if they could take the heat.
DSOPro: What do you think about how DSOs are evolving?
DSOs think they don’t have to. They’ve had it good for a long time. If you look at the whole healthcare system, it’s a $5 trillion industry, and dentistry is about 5% of that. Not much leverage at 5%.
Covid was a remarkably disruptive force. During the pandemic, I got to know people in the Santa Fe Group, some universities, and other groups that clearly demonstrated that dental disease is a comorbidity factor that leads to other illnesses and earlier death if left untreated.
Inside of some of these groups were medical insurers like Humana, Kaiser Permanente and Aetna, Medicare and Medicaid. They couldn’t help but notice the cost and severity of chronic diseases increased when dentistry was left untreated.
The rest of the industry understands that if you provide dental treatment to a type 2 diabetic it will impact both conditions. In one system I worked with, it cost $7,000 to $9,000 per year to manage a severe diabetic. If the patient’s periodontal disease was controlled, that bill would go down to $2,000. The whole industry went, “holy moly!” Tyranny of the obvious.
I did some work for Kaiser Permanente here in the Northwest. It’s a fully integrated system, too. Some of their dental facilities have physicians, nurse practitioners, and phlebotomists on site. With saliva testing, a physician or dentist can look at A1C and C-reactive protein and then access the patient’s healthcare record to see their treatment plan. By the way, at that time, dentists were on salary.
There’s so much that can be done to save money by incorporating dental into the system. DSOs need to figure out how to work, how to be “integrate-able” into the healthcare system. Just like physicians do.
The problem is that some DSOs are aggregating private practices with the claim that dentists can keep their autonomy and make their own decisions, but I believe those have a limited shelf life. Many dentists are in their 50s and 60s. It’s tough to find a good buyer for a solo practice. And an asset that’s not transferable is a liability. So, I see private practice turning into a liability, and its value going down.
What I see as the future is DSOs making themselves much more able to be integrate-able into the larger healthcare system. The money saved by the larger system, with the now forceful push by AI, insurers, government, and the public, will be the next evolution of DSOs.
Dentistry has been driven by mergers and acquisitions up and down a vertical, all contained within one silo. But I suspect that as DSOs grow, they will be more attractive to be acquired by larger medical enterprises that want a fully integrated system.
The Contemporary Elder Institute (CEI)
Dr. Cooper is the Founder and Chairman of the Elder Council of CEI. Our purpose is to transform late-aged professionals who have completed their careers from older to elder. Our mission is for these late-aged individuals to break through the encrusted cultural default future of getting old. Our intended results are for these elders to possess those qualities and characteristics of traditional elders but be able to manifest them in today’s world. Our deliverables for members are a noteworthy expansion of patience, self-understanding, empathy, equanimity, self-awareness, humility, adaptability, compassion for self and others, and attainment of higher wisdom and a higher purpose – which together alter growing old from capitulating to creation.
CEI is a Social Enterprise, a hybrid between a for-profit and a nonprofit. It has been in operation for over two years. Our membership ranges in age from 62 to 86. We are a national enterprise.