Dental Firm a Boon or Bane for Poor?

“I gave the working people a service for a price they couldn’t get elsewhere.”

--Edgar Rudolph “Painless” Parker, a controversial California dentist from early this century.

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By all accounts, “Painless” Parker, who set up shop in Los Angeles in the early 1900s, was a real piece of dental work.

Sporting a beaver-skin hat and a necklace strung with extracted incisors, Parker used traveling circuses, newspaper jingles and jugglers to promote business. The self-professed “king of advertising dentists” built a mini-empire of more than 25 clinics and 80 dentists up and down the West Coast--while critics derided his “assembly-line” dentistry as shoddy and dangerous.

Parker is long dead, and dentistry has made a lot of progress. But the more things change, the more they stay the same.

Today, the task of treating the working people’s teeth is being carried on by, among others, an even more enterprising successor: Western Dental Services and its owners, the Robert Beauchamp Jr. family of Orange County. Western’s dentists don’t wear beaver-skin hats or perform at the circus. But the Beauchamps, with highly visible advertising and free credit, have built the largest dental chain of its kind in the nation--a hugely successful empire of 115 dental centers serving 350,000 Californians.

And now the company is at the center of a storm in the normally quiet world of dentistry, accused earlier this year by the state of California of running the dental equivalent of a meatpacking plant and exploiting a poor, foreign-speaking clientele who often don’t know the difference. The FBI also is investigating Western Dental for alleged insurance fraud, and about 100 malpractice lawsuits are pending across the state.

Western emphatically denies any wrongdoing. Although the FBI probe continues, Western settled the state charges by agreeing to pay $1.7 million--the largest penalty the state has levied against an HMO of any kind--without admitting guilt. Western remains under a strict monitoring program while it implements dozens of specific actions required by the settlement to improve oversight and management of its clinics.

Western President Robert P. Schur calls the state lawsuit an example of regulatory excess based on a seriously flawed state audit of Western’s clinics that was not representative of the company’s overall performance. Schur said the state review targeted about 100 problem cases involving patient complaints or some of the malpractice suits pending against Western.

“We see approximately 1 million patients a year, and when you see that amount of patients, you are not always going to get the desired outcome,” Schur said.

But former Western dentists, the company’s former chief executive and dental association officials suggest that the firm--the nation’s biggest dental HMO of its kind--has become something like an abscessed tooth to the mainstream dental profession.

And the disclosure of certain allegations against Western--for example, that it performs multiple root-canal procedures in one sitting, ignores patients’ medical histories, uses poor-quality materials and does unnecessary work--has shaken a profession whose troubles rarely attract the kind of public scrutiny that is directed at general medicine.

“I’m not aware of anything that has approached this [the Western Dental case] in dentistry,” says Dr. Albert Guay, an associate executive director with the American Dental Assn. and a practicing dentist since 1960.

Virtually nobody in dentistry has risen to Western’s defense. Its own trade organization, the California Assn. of Dental Managed Care, refused Western’s plea to criticize the state’s action. Most of the group’s board, says a source, thinks Western “got just what they deserved.”

Hundreds of Dentists

The Western scandal, and the recent death of a Santa Ana youngster due to alleged negligence at a small dental chain also known for high-volume treatment at discount rates, have focused a spotlight on a growing corner of dentistry--the dental HMO.

Western brings together hundreds of doctors in a tightly controlled giant group practice. The firm directly employs dentists who are paid a salary, plus other financial incentives; most work exclusively at the 115 Western-owned clinics.

Western says its large network of clinics and centralized management produce cost savings that it can pass on to consumers in the form of lower fees, making dental care affordable to more people. For a $35 annual membership fee, patients can receive “40% to 50% savings” on dental work, according to the company’s marketing.

In a profession in which the tradition of solo practice remains strong and managed care is still in its early stages, Western found itself on the administrative cutting edge. Though the percentage of Americans enrolled in dental managed care programs lags far behind enrollment in medical HMOs, dental membership is growing rapidly.

Western Dental argues that in addition to reducing health care costs, its size and structure help permit better quality oversight and standardized treatment.

That’s much the same pitch that another troubled company--hospital giant Columbia/HCA Healthcare, now the target of a sweeping federal criminal fraud investigation--used to build its since-sullied reputation.

As told by former employees, regulators and dental industry experts, Western practices dentistry on the margins--often with heavily indebted young dental graduates unable to get solo work in a glutted market, for low-income patients who often don’t speak English or demand good care.

From the beginning, the venture that became Western Dental has served the poor.

Taking over his father’s practice in downtown Los Angeles in the 1940s, Robert Beauchamp Jr. saw the need for affordable dental care in lower-income, largely ethnic neighborhoods in California--neighborhoods that were, and still are, places where few dentists practice.

Beauchamp repeatedly bucked the establishment. In the 1940s, he sued the state Board of Dental Examiners over a law aimed at reining in the spread of dental clinics. He eventually found a loophole allowing him to open eight clinics in Southern California.

He began establishing satellite offices, hiring dentists and buying ads. By offering no-interest credit and discounted rates, Dr. Beauchamp Dental Clinics became familiar to generations of post-World War II Californians.

Long before doctors flooded newspapers and television with advertisements for tummy tucks, penile implants and snoring-cessation surgery, Beauchamp made liberal use of the media--and was derided by his profession. For many years, the California Dental Assn. refused membership to the Orange County dentist because he advertised.

“They [other dentists] used to hate me,” Beauchamp recalled in a Los Angeles Times interview in 1986. Beauchamp, now 85, declined to be interviewed for this story.

Today, Western promotes its services with bold red, white and blue billboards, television infomercials and advertisements targeting ethnic audiences. Its clinics are often located in mini-malls, next to doughnut shops or check-cashing outlets.

And its 425 staff dentists are the largest providers of dental services to the state’s poor.

Dentistry long has been a field that attracted people with an independent streak who liked the idea of running their own small business. And about 98% of America’s dentists still practice in groups of three or fewer dentists, with the vast majority in solo practice, according to dental school statistics. This gives the profession a decidedly mom-and-pop flavor.

For many, though, the desire for independence collides with an unsympathetic job market and their own indebtedness.

In many large U.S. cities, there are too many dentists chasing too few teeth. Many new graduates have difficulty finding jobs in an established dental practice, let alone trying to start their own. Meanwhile, the average U.S. dental graduate faces student loan debt of $75,000, according to the American Assn. of Dental Schools.

Pressure Called Intense

In California, another option for new dentists is going to work for Western Dental, whose rapid growth and relatively high turnover of dentists generates many job opportunities. However, these graduates often find that they are ill-prepared for what they find at Western, according to dental school administrators and others.

Driving Western’s operations, say critics, is a management demand for production so intense that dentists scurry among several patients at a time. The state charged that Western dentists, to maximize profits and win productivity bonuses, would perform too many procedures in single office visits--and perform dental work that wasn’t necessary.

Former president and chief executive Michael Silva, recruited by Western when it was under state pressure to clean up its operations in 1994, says he was forced out two years later after calling for an internal investigation of dentists’ complaints.

“The compensation policy at Western was a huge system of pressure to reward dentists who did the most amount of work the quickest,” Silva said.

Many patients didn’t complain about the care they received.

State regulators charged: “Many of Western’s patients are indigent, not fluent in English, poorly educated and thus more trustful of the dentist’s advice and less likely to complain about poor services than the average dental patient. Taking full advantage of this, Western brazenly flaunts its corporate credo that its patients are different, justifying its position that it does not have to provide the recognized standard of dental care.”

Western President Schur bristles at the suggestion that the company is taking advantage of the poor. Western Dental, he says, “puts patient care above profits and has a long history of taking care of the lower-income patients and making dental and preventive services available to them.”

In contrast to dentists in private practice, Western says, its staff dentists have less paperwork to worry about and have access to more affordable medical equipment and malpractice insurance. They are thus able to “contain costs” and spend more time with patients, the company says.

Schur insists: “The focus in this company is on patients and not on production.” The dental chain’s oversight of dental quality is the “toughest and most stringent” in the nation, he says.

Of the federal investigation, Schur expressed confidence that the government will find no evidence of wrongdoing.

Dental regulators point out in interviews that the vast majority of services at Western Dental are performed competently. But they say that state reviews over the past decade have shown repeatedly that an unacceptably high percentage of Western’s dental care is performed poorly and fails to meet state standards.

“If Ford produced 5% or 10% of its cars with defects, would you feel safe driving one?” asked one top state dental regulator.

Dr. Hossain Dezham, now in private practice in Sacramento, worked for Western Dental right out of dental school--a typical hire by the dental chain. He describes a “sweatshop-like” atmosphere during the years he worked there in the early 1990s.

“You were going from chair to chair to chair--there were 10 chairs--and from patient to patient to patient,” said Dezham, who managed a Western clinic in San Francisco’s Mission district. “You want to review charts but there’s hardly any time to or even to talk to patients.”

To maximize profits, he says, dentists were encouraged to perform as many procedures as possible in a single office visit, even if it kept patients in the dental chair for several hours.

This latter practice was especially common for patients belonging to Denti-Cal, the state-administered dental insurance program for the poor, he contends.

Dezham says executives at Western’s Garden Grove headquarters closely tracked dentists’ performance through daily “production” reports. He says big producers not only reaped bonuses and promotions, but won companywide recognition in a “Club 2000” bulletin that ranked dentists by how much money they generated.

The emphasis on production helped boost Western’s revenues to nearly $160 million in 1996, which was more than triple the level of five years earlier, according to data that HMOs are required to report to the state. Western reported net income last year of $6.9 million. But Department of Corporations lawyers say the company has produced millions of dollars of additional profits annually in the form of dividends to a Beauchamp family trust.

Dezham says he was reprimanded by a company executive for failing to perform three root-canal procedures on a Denti-Cal patient during one office visit--a practice he and state regulators say violated professional standards.

The final straw, Dezham said in an interview, was when a Western executive ordered him to step up production at the already-hectic clinic by 10% a month. “I can’t do that,” Dezham said he responded, then quit.

David Cain, a Sonoma County orthodontist who worked for Western for two years, says he was fired in 1996 after he complained to Western supervisors about the company’s use of low-quality dental supplies and substandard dental work.

Cain recalled instances in which Western Dental clinics referred patients with untreated tooth decay to him for expensive orthodontic work.

“I witnessed many problems where, if I’d not given a damn, I would have just slapped on those braces with cavities in their teeth,” Cain said. “And then, when the braces came off in two years, the patient probably would have needed root canal work.”

Familiar Complaints

Dale F. Redig, a former president of the California Dental Assn., says he got frequent calls from young dentists who had gone to work for Western and regretted it.

“These young kids,” said Redig, “would call the office and would be crying on the telephone about what was happening at Western.”

Dental experts say many young dentists are poorly prepared for work in a fast-paced environment in which dentists are encouraged to “turn over chairs” quickly.

“In one of these high-volume practices, a dentist might have 20 to 30 minutes to do the same work” that a student dentist needs two or three hours to do, says Dr. Ronald Mito, an associate dean at the UCLA School of Dentistry. Besides the cattle-call environment, Mito and others say, a familiar complaint from Western dentists is that diagnoses and treatment plans often are dictated by a clinic’s managing dentist, often over their objections.

In the state’s lawsuit against Western, regulators charged that Western management “interferes with the professional decision-making of its dentists because it believes that substandard care is adequate care for the economically disadvantaged.”

Silva, the former Western chief executive, was part of a new management team installed in early 1995 at the insistence of state health regulators who said they were fed up with Western’s repeated violations of state quality standards.

Silva says Western’s board--controlled by Beauchamp family members--fired him within a year, after he removed a nephew of Robert Beauchamp as head of dental quality oversight and sought an internal review of anonymous complaints from Western dentists about “a pattern of patient abuse.”

Western’s Schur dismisses Silva’s comments as sour grapes from a disgruntled former employee who tried unsuccessfully to put together a group of investors to acquire Western before he was fired. Moreover, he adds: “All of the accusations the department had against us happened on his [Silva’s] watch.”

From 1994 to 1996, Silva was employed as a consultant and then as chief executive. The state’s complaints against Western date to the mid-1980s.