The best of intentions
Several former employees said Kool Smiles started off with the best intentions. Doug Brown, a former paramedic who later headed a private ambulance service in Tuscon, Ariz., decided to start Kool Smiles after working with his brother-in-law, a dentist treating Medicaid patients. Brown said he saw an opportunity to have a viable business and to help children in need.
In 2002, Brown recruited two young dentists in Denver and opened Kool Smiles’ first office in Decatur, Ga., a small community outside Atlanta.
“The demand for service was unbelievable,” said Brown. “These kids had nowhere to go for years and years.”
The original plan was to open perhaps 10 to 15 offices. But Brown says he got an unexpected call from Friedman Fleischer & Lowe in 2004. The private-equity firm had considered buying another Medicaid dental chain, but decided to build its own chain. Brown said getting picked was a million-to-one shot. Though the initial investment was small by private-equity standards, in 2010 FFL tried to sell the company for $700 million but a deal fell through.
The company says it addresses the low reimbursement rate by freeing dentists from worrying about administrative tasks. Kool Smiles has a company called NCDR LLC that hires the dentists, finds new locations, owns the offices and equipment and manages the employees.
“It's what every professional practice aims to achieve, which is take the people who are capable of actually generating revenue and put them in a position to generate revenue,” said company spokesman Freeman.
NCDR is known at Kool Smiles for meticulously tracking data. The company distributes an “Office Scorecard” each day, showing each office a monthly and even daily ranking of how well they met revenue targets. A scorecard from September 2009 showed that for the month 34 offices hit their revenue targets while 24 did not.
“We always had to account for failing short of our goals,” said Christina Bowne, who managed an office in Portsmouth, Va.
On the other hand, she said office managers got bonuses when they hit their revenue targets.
“When you’re focused on the numbers, you remove yourself from the feeling of doing the right thing,” Bowne said.
Bowne said the system rewards dentists who bill as much as possible. Bowne herself was eventually fired days after reporting one dentist to the state dental board for what she considered improper treatments. Bowne's now suing Kool Smiles for wrongful termination. The company’s human resources senior vice president testified in a deposition that she was fired for falsifying business records and tensions with one or more of the dentists.
Megan Calimbas said she faced the same pressures as the office manager of a new clinic in Bryan, Texas in 2008. “We were just completely swamped,” Calimbas recalls. “While I was there I was working 60 to 70 hours a week.”
Although her office was a star performer on the "Office Scorecard," she says she was criticized for paying staff too much overtime. As a result, Calimbas said she was asked to leave after only five months on the job.
In hindsight, Calimbas thinks most of the dentists and staff at Kool Smiles want to do what’s best. But she thinks the mathematical precision of all those goals was unrealistic and doesn't account for the individual needs of patients.
While Kool Smiles acknowledges that offices have revenue targets, it denies that its dentists do. When asked if dentists have revenue goals, regional dentist Dr. Polly Buckey, speaking on behalf of Kool Smiles, said, “For our dentists, there are not. For our dentists, there’s not a number.”
However, contracts with dentists provided by Kool Smiles show that rank-and-file dentists can get paid bonuses based on the revenue they bill. The company provided a recent bonus plan showing that dentists are paid a base salary, typically $120,000 a year, or 25 percent of their billings, whichever is greater.
Kool Smiles acknowledged that their dentists get production based bonuses, but only after meeting quality standards. And they insisted that bonuses are not the same as targets. In a statement, the company said, “Dentists do not receive revenue, patient or procedure targets or scorecards.”
The Center for Public Integrity and FRONTLINE obtained several confidential internal documents, including one that ranks each dentist in the chain based on how much they bill in an average day. Another document lists a variety of metrics for dentists, including how many patients are seen a day, how many crowns dentists do and even how many areas of a child’s mouth they put crowns or fillings on in a single appointment.
In response to questions about these documents, Kool Smiles said dentists are able to see how they rank if they chose. It says the report on patients per day and other metrics is used to assure quality. But Kool Smiles says no one from the business side ever discusses these reports with the dentists.
The company’s chief counsel and senior vice president of human resources, David King, recently testified in a lawsuit that dentists have production standards. King testified that a doctor in Portsmouth, Va., was fired “not meeting our performance standards, basically production standards … She basically wasn’t meeting our targets around seeing a number of patients per day, quadrants of dentistry per day, those types of measures.”
Dr. Ashley Nichols, the regional dental director of Virginia, testified that the dentist was fired for "not meeting performance standards in terms of productivity."
Dentists who used to work at Kool Smiles said they were under pressure to meet revenue goals. One former Kool Smiles dentist, who asked not to be identified for fear of being sued, was asked how she met the targets if the children that day didn’t have a lot of dental problems.
“Oh my God, it’s a really hard thing to do. You have to do what’s best for the kid ... If you get in trouble, you get in trouble for not producing enough. And believe me, I got in trouble.”
Another former Kool Smiles dentist alleged in a federal lawsuit that he saw children being misdiagnosed and given treatments they didn’t need as a result of the financial incentives.
“Kool Smiles’ company structure rewards staff who performs multiple treatments on their patients — whether necessary or not,” alleged Dr. Baljot Bains, who was fired from an office in Bryan, Texas, after an angry confrontation with another dentist he had reported for allegedly misdiagnosing patients.
Bains wouldn’t talk publicly about his allegations, but in the lawsuit he said that “there was constant talk about production.” Dentists said they’d be told they needed to boost production, and that they would decide to use stainless steel crowns on small cavities as a way to increase revenue, Bains alleged. Kool Smiles denied the allegations in the lawsuit and the lawsuit was settled.
The financial incentive raises questions about treatment decisions at Kool Smiles for parents like Kari Reyes of Norfolk, Va. Reyes at first felt good about Kool Smiles. She trusted her daughter’s dentist there.
In February 2011, the dentist examined 3-year-old Marissa Mares and found eight cavities. She wrote up a plan for seven fillings and one crown. After fixing four teeth, the dentist asked Reyes to come back to take care of the four others.
But when Reyes showed up three days later, a different dentist examined Marissa. The new dentist rewrote the treatment plan, changing the fillings to crowns.
Reluctantly, Reyes agreed. The little girl slept through most of the treatment on laughing gas. But the new dentist couldn’t get one of the crowns to stay on. Reyes said the dentist kept pushing the crown hard against the gums, causing them to bleed. Suddenly, Marissa awoke with a jerk and start shrieking in a way that Reyes had never heard before.
“It was a very scary thing when she started screaming,” Reyes said. “It sounded like a painful scream.”
The dentist decided to have Marissa strapped down as the 3-year-old continued to scream and kick. Reyes couldn’t bear it and starting tearing up. “She was just stuck there crying, couldn’t move, couldn’t do anything. I couldn’t do anything to help her,” Reyes said. “It was really horrible.” Finally Reyes told the dentist, “Could you stop and numb her mouth?”
Reyes said the dentist didn’t respond. After asking again several more times, Reyes said, the dentist finally told her to be quiet. That enraged Reyes, who says she yelled at the dentist to stop and to get a different dentist. Reyes even followed the dentist out in the hallway, yelling.
Another dentist came in, numbed Marissa’s mouth and got the crown to stay on. There was still one tooth left to treat, but days later Kool Smiles told Reyes she couldn’t return. They now considered her a threat for her angry outburst. Reyes took her daughter to another dental office.
Dr. Robert Howell examined the tooth and said there was no cavity on it. It was just a stain that he polished off. In an interview, Howell said, “From my observation of the child’s mouth, she was very aggressively treated.”
The dentist at Kool Smiles, Trina Collins, defended her decision to put crowns on Marissa, saying that fillings were more likely to fall out. The chain said other dentists who have looked at Mares’ X-rays concur. Kool Smiles called the treatment “appropriate” and “in compliance with professional guidelines.”
Collins said the first dentist who planned to use fillings was young and inexperienced. And she said dentists can have different opinions on whether to use crowns or not, but that she had years of experience treating children.
A background check showed that Collins was thrown out of a pediatric residency program at Harlem Hospital in New York in 2009. The hospital leveled ten charges of misconduct against Collins, including falsifying a report and changing a treatment plan with no justification. In an interview, Collins denied that she did a residency at Harlem Hospital, but documents she filled out there give her current address in Virginia.
Reyes now questions whether her daughter needed all that work, especially whether she needed crowns.
“You know, they caused my daughter pain for their gain,” Reyes says. “It’s wrong to do that to a child.”