How to Support Dentists to Be the Best They Can Be - Dr. Rick Workman, Founder and Pat Bauer, CEO of Heartland Dental

Dr. Anushka Gaglani: I'm Dr. Anushka Gaglani. 

Dr. Abhishek Nagaraj: And I'm Dr. Abhishek Nagaraj, welcoming you to Raise the Line with Osmosis from Elsevier in collaboration with Areo Dental, an ongoing exploration about how to improve health and healthcare. 

Group dental practices are common now, but that was not the case before 1997 when solo practitioners dominated the space. We're going to talk today to a leading pioneer in changing that paradigm, Dr. Rick Workman, the founder and executive chairman of Heartland Dental, the largest dental support organization in the U.S. with over 1,700 locations nationwide. 

Dr. Gaglani: We're also joined today by the company's CEO, Mr. Pat Bauer, who has been an integral member of the Heartland Dental team since infancy. We're looking forward to exploring the fascinating evolution of dental practices in the US and what lies ahead for the field today with you both. 

Thanks so much for being with us today. 

Dr. Rick Workman: Thank you. Happy to be here.

Pat Bauer: Thank you. 

Dr. Gaglani: I'd like to start with learning more about you, Dr. Workman, and what first got you interested in dentistry. 

Dr. Workman: In thirty seconds or less, most people knew that I'd grown up on a farm, in a very small town with a three-room grade school. My mother was my teacher in first and second grade, and she said, “Rick, you can't write at all. You ought to be a doctor.” 

I tell people I was twenty-five years old before I realized all mothers told their children they're very smart and can do whatever they want to do. And so when I was in early college...I was transferring, and the physician who literally delivered me asked me, “What are you going to do when you grow up?” I said, “Well, I don't know.” I told him I might be a chiropractor. He said, “You know, you should be a dentist. I mean, those guys got it made.” 

I went on a trip a week later and happened to meet a lovely young couple, a dentist and his wife, and they were super nice. I thought, “Wow, that'd be nice to be a dentist, and not have to have your parents pay for the trip.” And so I thought, I'll give it a shot and here we are. 

Dr. Gaglani: Yeah. So Effingham, Illinois, right? That's where you grew up? 

Dr. Workman: Near Effingham, yeah. Effingham's a big town. It's 12,000 people. I grew up in a little bitty town. 

Dr. Gaglani: Really? Okay. 

Dr. Workman: My high school still exists. The last I heard, it has sixty kids in the high school. 

Dr. Gaglani: Wow. Thank you for sharing that. What's the backstory of Heartland Dental? What prompted you to start down the path of building this new model of practicing dentistry? 

Dr. Workman: I certainly never set out to do that. My goal was to end up not working on the family farm and not having to move home after dental school. I was able to find a place to rent an old dental office in Effingham when I graduated from dental school in 1980. I started practice and then a year later, I, again, more work. It's not a problem. It keeps me from working on the farm. and so I just opened up a second practice. Then the following year, I hired a doctor who was in the class behind me in dental school, and opened up a third office in a town of 1,700 people. It was really more of just like, “I think I'll try to have a group practice. Maybe this will work.”

Honestly, you know, eighty hours a week and about twelve years later was the first time I thought this might actually be a business model. At that time, we didn't really know what we were doing. We didn't really have the internet and there weren't folks that I knew that were doing this at all. And we thought, well, let's go. My first partner, Dr. Bill Bloink, who became a partner in 1992, is still with us today. We've had an interesting journey along the way, no question. 

Dr. Nagaraj: Quick follow-up question for that, Dr. Workman. So, twelve years later, how many practices were you at?

Dr. Workman: Probably, honestly, around twelve to fourteen. I think when we ultimately sold five years after that...so, from 1992 to 1997, we had about twenty-six or twenty-seven practices. We sold twenty-one and kept five. We were in a new corporation called Heartland Dental Care and so that's how we ultimately came to that name. It was like our seventh small corporation. Everything else sold, and we kept that one. And we go, “Well, that's just what we'll call ourselves from now on.”

Dr. Nagaraj: That gives me goosebumps that you're saying you were at twelve practices and then went to twenty considering where you guys are today. It just gave me goosebumps. It's amazing.

Dr. Workman: You know, I'd want to say this...I think that it's available for anybody to do. I'd encourage everyone who wants to do it to do it the right way. The right way to me -- and Pat will attest to this, too -- has always been to in our minds consider the doctors as our customers. We have to create value for them, respect for them and respect for dentistry. We have to understand they have to have the clinical autonomy and our job is to do everything we can to make their lives better and easier and always honor the patient.

As an older guy now, I sometimes see things where people want to slap things together. You know, “We'll buy them for five X, we'll sell them for twelve X.” I think things like that are not going to help us all in the long run. In my mind that doesn't honor dentistry. It's just a pure business ploy. I think you can do the right thing for the right reason. I think you can create value for everybody in the system. There's a lot of ways to improve a typical dental practice and improve the dental care and the delivery and service for everybody. I just encourage everybody to focus on that and eventually, if you do that, well....you know, God bless America, but there'll be value to be created and you can be proud of that. 

Dr. Gaglani: We couldn't agree more. We have the same mindset, so that's amazing. 

Dr. Nagaraj: Those are words of wisdom. Thank you so much. Pat, we'd also like to get to know you a little bit more, if you can share with us a little bit about yourself. What's your background and the career path that eventually led you to your work with Heartland Dental? 

Pat Bauer: I was looking for a job about thirty years ago. A dental group wanted somebody that had no dental experience. They had four offices at the time. They said they wanted somebody who was just going to help people because the two dentists weren't very good at it and I had background with people and operations. So, I started and learned everything I could.  

To Dr. Workman's point there, I met him in 1995 at a conference when I was with Metro Dentalcare back then, and we had very similar perspectives on doctors...how to help them be successful, how to lead the business from a doctor perspective and how we ran the business.  So, in 1997, he was selling his twenty-one offices or whatever the exact number was, and was going to start again and his management team said, “Hey, we need somebody like Pat Bauer.” And then Rick called me and said, “I'm looking for somebody like you.” Metro was involved with Delta Dental-owned practices back then and so it just kind of started changing the culture. I'm like, “Well, this guy has a vision.” So, in 1997, we joined. I think they had seven or eight practices at the time, in July of ’97, and then we moved from there. 

It wasn't easy. It wasn't like this is just a straight line. But the vision of how to keep our doctors satisfied, but also what do they need to be successful? Our whole goal is just to help doctors become successful because I mean, from a clinical perspective, how do you help a doctor? It's all about their autonomy. How do you help them understand what they're doing and why they're doing it and then giving them metrics to say, “Okay, this is what I deliver. This is what I believe. This is what I actually do.” And that combination, plus the alignment. 

We have aligned methodology with our comp model. So, the whole thing about Heartland -- and if you look at the success -- it's about alignment. It's alignment with our doctors, alignment with the owners, alignment with all the teams. That led us to be able to continue to grow because more and more people become successful, and when we’re around successful people, it breeds success with those doctors that have autonomy to have the kind of practice that they want. We just facilitate that. So, pretty cool. 

Dr. Nagaraj: That is super awesome. Pat, we have an Entrepreneurial Operating System (EOS) company. I'm sure you've heard of EOS. It's gained a lot of traction. It's based on the traction series: there's a visionary and there's an integrator. Right person, right seat. You define the data, the scorecard, the metrics...all that good stuff. Would you say if Dr. Workman was the visionary, you were the integrator who really thought about where the right people are going to go, which seats they're going to sit in, the ‘who, not how.’ Were you instrumental in doing that? 

Pat Bauer: Yeah, we're yin and yang. 

Dr. Gaglani & Dr. Nagaraj: (laughs)

Pat Bauer: He's the visionary. I'm not. He's like that small, less than 1% of people that are true entrepreneurs that understands ideas and how to make money, and then I can help him implement it with the right people and growing my leadership. In the end, it's all about our leadership being able to be successful. But without his vision, without his ability to see where it's going, how it's going to go...so together, we're a great team because he's so unique and so good at that. But an entrepreneur’s strength isn't putting organization and structures together. That's just not what they do, and so getting that combination has been super powerful. 

Way back when, we both read the book The Great Game of Business by Jack Stack and so we were both aligned on sharing Profit and Loss Statements with everyone in the whole company. Everyone knew how we were doing, not only in the office, but as a company. And we shared the metrics. That benchmarking with each other -- from patient satisfaction to what do you believe you should do when you do a filling, a crown -- all of that was already in his mind. “Here's how we help doctors make the right decisions for their customers and their patients.” That alignment and that combination is amazing.

Dr. Gaglani: It's facts, not feelings, right? 

Pat Bauer: Yes. Because everybody has feelings. You ask a doctor, "What's your case acceptance on crowns?" And they all say, oh, 80-85%. "No, really, what's your number?" They'll say it has to be 85%. "No, really, what's your number?" And they don't know.  

Dr. Workman: And it's not 80 or 85%. 

(all laugh)

Pat Bauer: No. Not even close. 

Dr. Gaglani: And you're diagnosing 10 crowns a month, right? 

(all laugh)

Pat Bauer: Exactly. 

Dr. Nagaraj: Or doing all prophies.

Pat Bauer: (laughs)

Dr. Nagaraj: Totally. Dr. Workman, I heard you on a recent podcast -- we listen to a lot of your podcasts -- and you said that if doctors can't be measured, there's no way we know how to improve ourselves, right? Speaking of that, what were some of the early innovations that you brought into the technology? What were some of the early innovations that you brought into the dental practice? You were obviously years ahead thinking about some of these things. What were some of those early innovations you brought? 

Dr. Workman: I think I would attribute the fact that we were one of the first Dental Support Organizations (DSO) started by a dentist. I feel like I had an intimate understanding of the pain and the pleasure, I guess, of being in a dental practice. I understood the challenges that a dentist faced and the opportunities, all the complexities. We taught our core people that. They grew up in that. And so, in some ways, some of the early innovations were simply, “Wow, I've seen that. I've experienced that and I can tell you how we now do that.” It's not how maybe we were taught in school or the attitudinal approach by the academicians that we met. That's a certain approach and it got us where we as an industry, got, let's say, into the mid-or-late 1980s. But we found eventually that maybe there's a better way to handle that, or an innovation.

I think my first article for Dental Economics was about benchmarking. As the saying goes, ‘ignorance is curable, stupid is for life’ and there is a certain level of ignorance about measuring for quality assurance, measuring for your own personal health, measuring for your own personal accountability. When I was measuring myself and what I did, what does it really look like in the outcome? And then how is what I do similar or different from other doctors? So, we measure those benchmarks. And nobody knows the answer. I don't know the answer, but I think we as an industry ought to study that. 

Because in oncology, you know the answer of the survivability rate based on the type of cancer, based on the stages diagnosed, based on the treatment. You know that. If you're a cardiologist, you know probably what the ratio of stents to open heart surgeries is. You know the conditions and when you do one or the other. Well, we can argue that dentistry is maybe a slightly less exact science, but we ought to have an idea. We ought to have a discussion about it.

You know, when I started, I hardly knew any general dentist who ever probed. I mean, ever probed. I talked early in the late 80s about that. My point is this. Can we have a discussion about whether or not your patients are getting proper diagnosis for periodontal disease or not? What percentage of your adults are getting treated for periodontal disease? I'm not here to tell you what it is. People much smarter than me would know that. But the answer is probably not one or two percent and it's probably not ninety percent. So, let's talk about the process. Make sure we do the process and then let's study, act and come up with a system that has the best chance of a repeatable quality assurance program. That's an innovation I think we're kind of proud of that we think we've tried to help a little bit. 

Dr. Gaglani: Yeah, that's a really great point...kind of have standardization so if you have a different doctor going into the same practice, it's the same experience for all patients. I love that. And I'm going to use that quote...I love that quote ‘ignorance is curable.’ 

Dr. Workman: ...”and stupid is for life.’

(all laugh) 

Dr. Workman: Or my other favorite one that I definitely lifted from a former doctor friend is ‘dogs bark at things they don't understand.’ But we as professionals and we as an industry, I think, owe it to ourselves to simply investigate that. We ought to be able to talk about it. And it doesn't mean it's a quota. That's what the haters would say. But it's like, let's talk about it. What percentage of your adults do have periodontal disease and what percentage are you diagnosing and treating? One of Pat’s good examples is...let me ask you doctors...do you believe that a new patient should have an examination? 

Dr. Gaglani: Of course.

Dr. Workman: Okay. Well, guess what? Measure it, and I'm here to tell you that 100% of your patients do not get an exam. You say they deserve it and you definitely want to do it, but they don't. And the question is, is it 96%, 92% or 88%? There's an area of opportunity there to become better by simply studying what percentage of our new patients got an exam. Nobody thinks they shouldn't get an exam, and yet they don't get it and that'll be a big discovery. It’ll change your life when you figure that out. 

Dr. Gaglani: Yeah. Great points. Thank you. So, Dr. Workman, did you ever imagine your business would grow as much as it did and why do you think it took off? 

Dr. Workman: The answer is no. One thing that we always strive to do -- and I don't know if it was the good things or bad things about just the way I was raised -- but we can try to get better next year. We can constantly try to get better. If we get better, maybe we get a little bit bigger and a little bit better. We can have a discussion about whether we're better, but we're definitely bigger. I think we're both. I think we've learned so much in the past year that we're so much better. So, over time, people joined us. They chose to want to join us. Many people chose to stay with us. We're not perfect, but we say our batting average is pretty good.

If you treat people right, try and do the right things for the right reasons -- again, I'm not suggesting we're perfect -- but I'm saying most people who've been around us for a long period of time know that our heart's in the right place. We're trying to do the right thing and we provide an opportunity for careers for lots of people -- doctors, hygienists, business assistants, dental assistants, administrators, and so forth. If you take care of your people, the world will beat a path to your door, so to speak. We're trying to do that, and we've been doing it for a long time. 

Dr. Nagaraj: Quick follow-up question there, Dr. Workman. I heard a story about...I think it was Dr. Samson Liu who trained with you for the longest time. It was in ‘1999 in Effingham where you were training a bunch of dentists, and he wasn't really paying attention. You called him into the room, and you said, “Hey, doc, this is my vision. We're going to get to 1,000 practices in ten years.” This is amazingly visionary stuff. Were you raised to be a visionary? Or did you sort of expound on that over time? 

Dr. Workman: It is a true story when he was there for a new employee orientation. Samson, you know, is an extraordinarily highly skilled person with very unique skills. When people wonder how certain things get done, sometimes we all, as humans, have to realize there are geniuses out there. There are geniuses who can do things that we couldn't do.

If you're a dentist and it takes you an hour to do a crown prep and somebody tries to tell you can do it in five or seven minutes, too many dentists in the world think, “Oh, that's terrible. It's just, gosh, that's inhumane to do that.” And then you watch people do it and you're going, “Well, why would it ever take longer than that? That looks really nice.” (laughs)

I don't remember exactly that I said we're going to go to a thousand practices, but in one of those rare moments, I said, “Really, what do you want to do? Where do you want to be?” He said it focused him to make a commitment to be really good and he has gone on and done that.

In the nicest way, I'd like for all dentists to end up with the ability to say, “You know what? I am making a commitment to be the very best person that I can, the very best dentist that I can.” We can be average and have a great life as a dentist, but there are many who go, “If I would apply some intention to what I do, I can accomplish great things.” I encourage all dentists to try to do that.

Dr. Nagaraj: Thank you, Dr. Workman. Pat, can you help us understand a little more about the size and scope of Heartland Dental and what place it generally occupies in the marketplace?

Pat Bauer: Well, I think we're seventeen hundred plus practices in thirty-eight states and D.C. What did we do...about $3.2 billion in revenue this year. Again, that's not the important number. The important thing is that our doctors are really happy.  If you look in the whole perspective, we’re maybe only two percent, maybe a little over two percent of the market. So, when you think about that, we're pretty small in the big picture of dentistry. But our size gives us power, gives us leverage and that's the difference. The bigger we get -- as long as our culture stays -- then we are unstoppable. 

What Dr. Workman was just talking about there is all of that planning. We’re really good at planning. We are really good at strategy, trying to figure out where we're going next. What's happening in the external environment? Where are we going? Where's the world going? We've been doing that for about twenty years and so we just keep on getting better at it. We weren't very good at it twenty years ago (laughs) but we're much better at it today.

And understanding here's our flywheels that we have to get going. We cannot ever slow them down. From selecting the right patients for our doctors, to getting the right providers, hygienists, doctors, growing our footprint, operational excellence...all of those things are part of it. Then getting leverage from our support office, but being world class at it. And again, we’re not perfect by any stretch of the imagination. We're always getting better, but understanding where the future is going is the difference and always keeping our culture with our doctors leading their practices. 

There's a big difference between some DSOs and others, and that's a major point that our doctors are in charge of the practices. We're there to support them. That doesn't mean we're perfect at it. Doesn't mean that they're great at leadership. So how do we help them? The significance is, Heartland is leading the pack. Our vision is to be the leader in dentistry so that we understand where the world is going and we know it's changing drastically.

We're going to implement AI across all of our offices this year. Well, that's a massive transformation for our doctors to understand it. They'll be better clinicians for their patients and their communities if we implement this correctly. But we don't just shove it down their throat. They have to embrace it because they're the doctor. We've been testing it for how many years? Three or four? 

Dr. Workman: Two or three or four. Somebody told me five years and I go, oh my God! 

Pat Bauer: Yeah. But it's a process. And we finally got our doctors to say, yeah, this is the one. We had two that were the best ones, and then who do we negotiate best with? Then we give that to our doctors and say, okay...it's been vetted by doctors. So, how do we then help them get that?

Those are the kind of things when you see that the impact we can have in dentistry long term is just massive. The bigger we get, the better we get, the more power we get, the more supplies we get. Our doctors get the best. I mean, our supplies are the best products at the best prices, I promise you, in the world. But that's the power that we have. 

Dr. Workman: And we have to, in our mind, judiciously use that. We have to work with our vendors and suppliers, create value for them. We think we do. We're not perfect. Some people, if maybe their product doesn't get used as much don't like us as much, but they do know that we run a process. We give everybody a chance to pitch their products. We have doctors testing products and equipment all the time and it's the doctors who make the decisions about which products are going to be in our practices.

 

Dr. Gaglani: I love that. True economies of scale, honestly. How does the corporate practice model benefit patients and patient outcomes? And a follow-up to that, how does it benefit providers?

Pat Bauer: Well, I mean...it's called corporate practice. It sounds like a bad term, first of all, like you just swore. 

Dr. Gaglani & Dr. Nagaraj: (laugh)

Pat Bauer: Because it's really just group practice. People call it corporate, but it's really group practice. We are one group practice. We affiliated with a group practice that had twenty-two separate groups and it was chaos. We are one. We have regional differences and regional things, but we are one group practice. We have over about 1,100 doctors who have over about $250,000 in stock that they paid for with their own money in Heartland Health. That's a true partnership model. So people say, “Oh, it's corporate.” Well, we have to have structure, but it's a group practice started by a doctor for doctors, and so it's not really corporate. 

It's really about helping the communities. We're a collection of hometown dental practices in many communities, helping their communities have the best dental care. And so they call it that because they don't know what else to say, but I've been doing the same thing for thirty-six years. It's literally helping doctors when I was with four practices to now. 

Dr. Workman: I would say I'm happy for solo practices to be happy and successful. I'm happy for general dentists or dentists of all specialties to be happy and successful. My life's work has demonstrated that not all dentists are happy, nor are they successful and sometimes it just takes a little bit of help and support and guidance to make a big difference in their outcomes.

You know, if you were going to build quality assurance -- a repeatable standard of care -- the last thing in the world you'd do is have it all be individuals in a silo doing their own thing. That's the last thing you'd do for quality assurance. Now, I admit that freedom and flexibility -- and I love freedom and flexibility from my personality type -- is wonderful in a solo world. But quality assurance systems, repeatability and accountability are not the hallmarks of an individual. So what we can do is we can help people. 

By helping them -- and I know people sometimes criticize me on this -- but sometimes we help them by having a 1-800 hotline so that if their words are slurring, if their hands are shaking, if they're doing something that's inappropriate, that they can be reported and we can help them.

I heard years ago that in Kentucky, one out of every seven dentists was practicing in an impaired physician plan. One out of seven in the entire state of Kentucky. That's what I was told. Sometimes we as humans need help, and we can do that.

Sometimes knowing that somebody's going to audit your charts will increase your accuracy of billing. There’s the example of the oral surgeon in Oklahoma, it's been eight years ago, who reused IV needles to save money. His team didn't turn him in because they knew he'd lose his license and they'd lose their job, so they were complicit with that.

I don't see how that's possible to happen in a DSO-supported practice. They'll just get a new dentist. They'll help that dentist with whatever problems they've got. But for the patients, they'll be better off. So, there's a lot of discussion and I think we're entitled to have this discussion. It is a discussion that needs to happen because it's the real thing in the real world, and sometimes it's not tidy. 

Pat Bauer: That's the base of thought and state of mind. When people have that, oh, we're just trying to tell people what to do. Well, then, actually, if you believe that, no matter what I do, the consequences, you think we're trying to tell somebody what to do.

But if you really believe all we're trying to do is help a doctor make the right decisions for themselves and their patients, well, then it changes everything because we don't have a quality assurance program where we're looking over people.

We have a quality assurance that we're trying to help the doctor make the best decisions. And that's a different base of thought and state of mind. And so but if you have the basic thought that, oh, we're just trying to tell them, well, I can't win. No matter what I do, you're thinking it's corporate and we're trying to tell them what to do. No, no, no. The doctor still makes the right decision if they have the right information...

Dr. Workman: Yeah

Pat Bauer: ...if they're challenged in their thinking to be the best that they can be, and that's just a different way of thinking. 

Dr. Gaglani: Well, thank you for that distinction between corporate and group dentistry, first of all. I think we definitely agree with that as well. So, thank you so much, Dr. Workman and Pat Bauer, for being with us today. I'm Dr. Anushka Gaglani. 

Dr. Nagaraj: And I'm Dr. Abhishek Nagaraj. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the health care system. We're all in this together. It was a pleasure having you both. Thank you so much. 

Pat Bauer: Thank you. 

Dr. Workman: Thank you, guys. It was an honor to be here.