An Interview with a Medicaid Chief Dental Officer (Dentaquest)

[MUSIC] >> Set down your sleepy water in your Mr. Wessel. Take off that raincoat and grab a cold beer. It's time to have a real talk about pediatric dentistry. You're listening to Bruce and Tiny Teeth, the unfiltered pediatric dentistry podcast. [MUSIC] What's up, Bruce and Tiny Teeth fam. Sir Boy Casey gets Medicaid. That's the topic of today and I literally have the perfect guest. We just recorded a killer episode. Did it late in the evening. I had a little bit of bourbon. He had a glass red wine, but I ran into Dr. Todd Gray. Todd Gray and I connected at APD this year. He is the chief dental officer of Denequist guys. And at first I didn't quite conceptualize the implications of him and his role in having him on, but he was a fantastic guest. We kind of got together at APD and had this idea where maybe we could do a podcast episode shedding a little bit of light talking about what it looks like on the inside of managed care of Medicaid. And Todd's going to talk all about that. What managed care is, how Medicaid's working the states. He shares a lot of insider things, being that he's unique in that he worked as a pediatric dentist for 15 plus years. And then transitioned into this role of working on the dental insurance industry or the managed care industry for Denequist, which Denequist, I think I can remember how many millions, 20 some million people it provides Medicaid services to. And so whenever anybody's complaining about this didn't get approved by Medicaid or my fees are too low or people are having all these grievances with Medicaid. He's kind of part of the cog and the big machine that runs all of that. And so it was really cool to pick his brain and him give some insight having been both in the trenches pediatric dentist and working on the Medicaid side of things. So I have a great conversation learned a lot from him. I also didn't do it a ton of justice, but you know, Todd's he's an ambitious guy. He was private practice for a long time. Of course, in the Medicaid kind of call industry now, but he also has, you know, in his spare time, we were talking about a APD when we were standing next to the Medi-Denta booth, but him and Dr. Sean Whalen, who's another killer pediatric dentist out of Colorado. Those two guys put their heads together and also have a dental supply company. It's called SMIL, but I think it's important to support our fellow pediatric dentist and kind of the endeavors that they're doing. This is one of those things where they put their heads together and they've started coming up this dental supply company where they have access to a lot of great prophy products, prophypaste, varnishes, and they have them at really super durchy prices. Really good stuff, guys. So I wanted you to check them out. I'll put a link, I think I think it's SMIL 20, but those guys wanted to give a discount code. So the punchline is if you're still ordering your varnish and your prophy supplies from like Patterson or Shine, you need to wake up because it's 20, 26. There's far cheaper, better ways to get these supplies now. And I think these guys have a solution for it. So I just wanted to support my fellow pediatric dentist that are trying to make things better cheaper, faster, more efficient. And I think this is one of those. So check them out, SMIL.com, S-M-I-Y-L. Otherwise, I will also say this podcast as we were recording a big storm came through and I had a few internet hiccups, you know, perks of living out in the country here in Missouri. But got it all clipped together, I think it sounds really good. I think you guys are really going to enjoy this episode. And my hope is that it sheds a little bit of light on Medicaid, makes it not so daunting, kind of makes it feel a little bit more like there's real people behind, you know, this big scary monster that's Medicaid and that it's not all just bad guys and they have rules, they have to stand by. And we talk a little bit about, you know, fee structures and that sort of thing as well. So a lot of good info in this podcast, especially if you take Medicaid, might be taking Medicaid when you start associating or you have a practice and you're considering signing on for Medicaid or through an MCO. So with that being said, guys enjoy the episode. Cheers. Okay. So yeah, kick this off. I said it's nice doing these podcasts after hours with a drink, but I went for a, I made an old fashioned. Are you a bourbon guy? Do you drink? I see you're a more of a red wine guy on your end, right? Yeah. I'll drink bourbon. Yeah, I enjoy bourbon. I have a glass of red wine tonight. This is a bottle. My dad gave me. It's called Taken. It's a napah Valley red wine blend. I'm not sure what's in it. It's pretty good though. But it hits nice. Yeah, I'm, I've been on a bourbon kick too. There's a couple really good distilleries in Missouri. And so I, I like a little sweetness. So I kind of, I do a little old fashioned, but I like a little maple, like real maple syrup and then doctor it up. And I've been trying to cut back a little on the during the week alcohol, which I felt like it's a bad sign if you get a bad clinic day and like all my kids were terrible, like all my ops were horrendous today. Nobody was age appropriate. So I was like really looking forward to having a podcast where it gave me a double excuse to have a drink. I feel like I earned it after a couple of tough ones today, but you remember how those days you get a couple bad ones once, once in a while. And there, I've been there many, been there many times and it's, yeah, you kind of got to leave it there and think about the positives of the day and the differences that you made and then you reset, right? Like you're doing right now. So yeah, I think we've all been there. Yeah, yeah. Yeah, that's funny because you can fix up, you know, 10 kids in a row and they go great and you crush it and they don't feel the injection and your feeling looks perfect and everything mom's so happy. And then you just have one that doesn't go quite perfect and that's the one that you dwell on all weekend, you know? Absolutely. I've done that so many times and like your example, you take a child that is scared and difficult and you get them comfortable and you get through an incredible op and you're like, oh my God, I can't believe that. It went so well and you're grateful and the mom or the families that go, thank you. It's so awesome. It did so well and you're thinking yourself like I just nailed that like nobody could have done that as good as what I just did. I feel so good and you might have even four of those and or five of those and you get one that you think goes off the rails and you beat yourself up over it and it's, I think we all do that too. And it's not really fair, you know, I've tried over the years as I practice, I tried to not focus on those things and focus on the good. And then if something goes off the rails, you try to, I try to look back and I would say, could I have done something differently? It wasn't me. Was it the way I interacted? Was it was it a technical thing and how I was, you know, doing my sort of dentistry? Was it a personality thing? Was it that I not read the room correctly? You know, all those things come into play. I think the more that we look back, we start to gain that wisdom and that is really how you learn and that's how you improve it. Easier said than done because, you know, we all want to be perfectionists and we all do the best so we can do at least most of us do. But it is definitely something worthwhile to try to look back and do that. I think it helps all this, especially on pediatric dentistry. If we give ourselves a break every now and then and you know, take some time, take a beat and say, you know, maybe it was a tough day, but you know, tomorrow's another day and you'll be right back at it. Yeah. Yeah. To second that, you know, I feel like I've been practicing long enough to your point where, you know, you've kind of been through the same tough situations a few times where eventually you get to the point where you know, like, I know it's not just me. Like, it's, I'm maybe, what am I trying to say? Like, this wasn't necessarily me doing something wrong. Like, I feel like I communicated right. I did my dentistry correctly. This was like a parent problem. So you, like, over time, as you've been in those same situations a few times, you start to, you know, you see the same situations pop up. Like, Crunchy Mom didn't want to take X-rays and then, you know, a cavity popped up and then she was mad and then eventually you've done that a few times and you start to realize it's not a me thing. This is a difficult parent thing. So you start to lose less sleep. I'm on your six now and I'm feeling that more and more. So after, you know, I know you practice for quite a while, but I could see how after you do this for a decade or two, you kind of, you know, there's nothing really that surprises you and you kind of learn to roll with it a bit more. Yeah. I'm laughing when you said, Crunchy Mom gets mad because she's on an X-ray and then you, later on the child has an interproximal decay and now it's, yeah. Boom. Yeah, no, I agree. I think one of the things that really have enjoyed about the profession of pediatric dentistry is we have such a great community, Casey, that you need to surround yourself with your peers and your friends who are living this with you. So, you know, I have a really good network of colleagues that we, you know, pediatric dentists that we lean on each other. If we have difficult scenarios of situations where we want to help each other out, we're always there for each other. It's just a great community and I think it's a special person who goes into this field. I think that it's just, it takes people that care and that are truly empathetic. And you know, like when I went into pediatric dentistry, you know, I grew up in my dad's at dentists. He's practiced endodontics for I think 45 years, practiced, practiced into his 70s. And you know, when I went in, my sideline was like, I want to work with children. I had done, you know, I had done some coaching. I after college, I worked in the county school district and my intentions were, you know, when I go back to school, you know, I'll probably go to dental school just make sense. My degree is in biology and my aim was to work with kids and young adults. And I think that the greatest thing that some of us get out of it because you hear people say, why it's going to dentistry and the patent answer is I want to help people, right? Like it's and I, but I think that's really true about pediatric dentists because when you get into this, you realize how many people you can touch in a positive fashion, right? How you can, you can take time to interact with them. Yes. you're doing dentistry and obviously you're putting them in a healthier state and you're making their lives better. But if you really take the time and I always try to remember to do this when I was in full-time practice is take the time to get to know the people that are there whether it's the grandparents, the parent, the guardian, the brother, sister, the family. Take time to talk to them. Regardless of how busy you are, take a pause and listen to them and get to know them. That's the greatest thing that we have in our profession. We get to see these children grow up and we get to see them at least twice a year, so much more than that. But it's getting to know those families and building that trust and building those relationships. I started practicing 22-23 years ago and I run into kids now that are full grown adults and they recognize me. And they say, "Dr. Gray, I'm so-and-so." It's such an awesome feeling to be able to do. I see somebody get to watch a generation of children grow up, but it's really those relationships that you build that makes a good day. That's something that I think is the most rewarding of our profession. It takes a special person. That's why I think we have such strong community. Yeah. Let's set that as a groundwork for our conversation. To kick off what you and I got together at APD here a few weeks ago and came up with this idea to do this podcast because I thought you might have a really good, unique perspective being that you were a full-time pediatric dentist in the trenches, work in seeing kids like most of the listeners of the podcast and then had kind of a career shift to get it inside to the world of insurance. So I thought maybe to give you some street cred here, if you will, about your background as a pediatric dentist, maybe share with the listeners a little bit about your practice history. Kind of bonded over the fact that we're both Iowa grads, which was really cool, but maybe touch on that and then what your practice life looked like over those two decades or so that you were in the private practice world before making that transition. Yeah. So yes, we're both Iowa grads. Awesome training ground. I still rely on folks from Iowa all the time. Went to dental school there and then got into the residency program and completed my residency at Iowa. I always felt the University of Iowa, a couple of things they taught me. It was one and Mike Cannellus was my program director. He's still around the university and I ran into my APD. He had a great conversation. He hadn't seen him forever, but he just said, you know, he was good to all of us and he taught us a lot. But Mike was big and when I went through the residency, there were still remnants of people teaching handler mouth and like really aggressive behavior management. But we didn't do that in Iowa because we had Dr. Cannellus and he approached it from a kindness and he passed it on to me and to all of us. And he showed us a different way, right? Get in there, earn the trust, interact with the children, interact with the family. Like we said, sometimes they're going to be tough scenarios, but you know, treat them like you want to be treated like you want your child to be treated and there are ways that you can make that happen. So I feel like I got a really good training ground, but when I got out into private practice, I started my own practice. I think I think somebody you right out of the gate and so went through some of the, some of the ups and downs with that. It was a big struggle to try to keep the bills paid in the beginning and you know, got out, moved out to Nevada where I'm from and we I set up shop and rule Nevada in the Carson Valley, which is south of our state capital, Carson City, it's about an hour south of Reno, which is the town that I grew up in. And really just jumped right in and the first day I saw I think I had four kids on my schedule. And I remember that moment sitting down in the chair of the first patient being like, am I qualified to actually do this? It was like a four year old and two year old sister and it was such an awesome experience, but they were my patients until they graduate high school and all four of the kids that day, you know, were the same boat. They stuck with me and with my team at a great team, great support staff and we really built like a community and our small town and drew from all around the surrounding areas of rural Nevada and North, North Eastern California. So yeah, we started four kids a day. By the time I sold my practice to my associate who still owns a practice and we're close friends and she's awesome. And I think we were seeing about 800 kids a month and averaging around maybe 80 to 100 new patients a month still. So we were continuing to grow. We went from barely being able to keep the doors open to moving to five days a week to then eventually bringing on associate and we had quite a bit of full mouth decay in our area. We were only practices for miles that that took Medicaid benefits that got me involved and working at this in with our state Medicaid agency because I helped out some projects and you know, provided advice when I could became the dental director for a special needs clinic for adults and children in Carson City called Eagle Valley Children Center and we would go up every six months and bring a portable equipment and clean their teeth and do things that you probably did in Iowa with these large non-children patients where you're trying to use a tip together tongue depressors so you don't get your fingers bitten off and clean their teeth and diagnosed at the same time. But it was great. It was a great experience. My team was awesome in supporting that and you know, we did that for a number of years and it was something again that I learned at Iowa was you treat everybody, you treat everybody. You know, you give everybody an opportunity to get in for care regardless of what their socioeconomic background is or their health history or whatnot and it was a great experience. So we grew that practice and eventually so that practice to my associate and that was kind of the first phase of my career. You a couple side questions there. So you ended up practicing, I was just trying to put a timeline in an age on this. So about were you practicing what 15 to 20 years and about how old were you and what prompted that transition to start saying I need to face out of the clinical side of dentistry. Yeah, so when I started my practice, I believe I was 34 because I didn't go straight to dental school after college. I worked like a seven school district and did some coaching, did some different number of different things. And practiced until I was practiced for, I want to say 14 years, providing care. 13 in my first practice and then I did some part time practice with some other groups where I helped out in new petal practices or filled in days as I transitioned over to the new career that I've been doing for the last 10 years. Okay. Was it, was it, I can't remember if we talked about this at APD, was it health reasons or was it, was it burnout? Was it you just wanted a different challenge? What was it that kind of prompted that change to move out of private practice into the insurance field? Yeah, not health reasons. That was an issue. Yeah, I don't even know that it was burnout. I think it was more just taking a pause and looking to see like if I could go in another direction with my career. And like I said, I still come my foot in the door. Now I practice with two other friends practices in the area of providing services like two, maybe two days a week. But it was, it was always kind of my, my desire to, at some stage in my career to shift into, it kind of went down a different route and see where it took me, but stay, stay in dental because that's obviously where I'm at background was. So right when I, where I'm going to soul my practice to my associate, it was when the state of Nevada was switching over to managed care. And because of the work that I had done with the state and I knew some of the folks there, when that was occurring, one of the people from the state agency reached out to me, email it's random email and said, Hey, you know, there's this new organization that's coming in to manage care and Medicaid for the state. Would you be, you should, you might be interested in applying for this role. And the timing, it was just certain dipitus that it was, it was right there. And I kind of looked at it and I didn't know what it was. It didn't really know a whole, really didn't know anything about managed care. You know, I just practiced in dentist and, you know, whatever. But I just said, you know, I'll, sure, I'll throw my hat in the ring and put in an application to see what happens. And they were kind of further along into the application process at that point. I don't, I think I maybe got it in the last minute. And that was a Liberty Dental plan who had the managed care contract in Nevada. And so I, you know, I flew down to California and met with their, with their team and interviews and when they offered me the position and when I started out, it was like, you know, part time dental director for the state in Nevada. And, you know, that's kind of, that's how it got going. And that's how I started learning about the industry. But I had a lot to learn. Like I knew very little when I first got into it. And I think that what they're looking for was somebody who could, who understood the, the industry as far as from the clinical side, who understood what dentists are doing experience. Somebody who was willing to speak and to kind of be the face of the program in that state. That's kind of what they're looking for. And I just happened to be right guy, right place, right time. So fell into that. And that was kind of what got my foot into the door into the insurance or benefits industry. Just to be respectful of the younger docs that maybe aren't in private practice or associates or don't know the lingo, you know, and I, well, we had a good background of like treating kids with Medicaid and. And obviously we talked about C Medicaid in my practice. We have three managed cares in organizations in Missouri. I wanted to make sure that you maybe help define for those that are listeners that are younger, docs, or aren't familiar. Could you kind of explain what is managed care just to kind of put a definition and help people sort of understand what that, you know, people here manage care and Medicaid in the same context a lot of times. But unless you own a practice and you work with Medicaid, they may not know what that means. So could you just kind of extrapolate on that for some of the younger listeners? Yeah, sure. And I totally get it because it is confusing. And I didn't know anything about it until I got an industry. So managed care is so Medicaid is part of managed care essentially, right? So what managed care is is an attempt to run a more streamlined quality, focused, insured that access is there for patients and members. Quality outcomes for the patient, quality outcome for the dentist, cost savings to monitor a non-medically necessary treatment because the thing I remember in a Medicaid field, the money is that good to pay for the treatment, whether it's dentistry or medicine, whatever is systemic health. That comes from the state from the federal government. So the state funds a Medicaid program and the federal government matches that funding. A minimum of 50%. So it's funded through two sources. State decides what they want to fund. The government matches at 50%. They can match more depending on what the per capita income is for the state. So for example, Mississippi is, I believe somewhere 74, 75% match from the federal government, whereas New York's 50% because the per capita income is higher. But anyway, it's funded and it's federal, it's taxpayer dollars and it's how the state decides to spend their money. So that's what I think is, with my understanding being that when a state has a hard time, at a state level they can't have, or if they don't have the manpower and the resources to administer the plan, take the phone calls and keep track of everything, they outsource it to third parties or private companies, which is in my managed care because it can often be done better and cheaper and more efficiently. And that was kind of my initial understanding of what managed care is in Medicaid. So I was just kind of hoping you could kind of define and expand on that a little bit more. Yeah, no, you're exactly right. So what I mentioned earlier is that Medicaid is co-funded by the federal government and by the state. And there's a match rate, depending on what the federal government pays and what the state pays, but it's at least 50%. And it can be higher depending on what the per capita income is for the state. Your understanding of how it works is essentially correct. But it's not necessarily maybe that a state can't. It's what a state chooses to do. So the different models, they can choose to go a straight fee for service model, which is where you would perform a procedure or submit a claim and it gets paid by the state and it goes straight out to you. They can do something where they do a third party ASO agreement where you're just someone's company is outsourced to just be the back office. So they're just handling the claims, but the state still owns the network and still kind of controls the program or they can go into a fall on managed care, which is called a risk arrangement where the state says, I have a set amount of money. It's predictable because I know what it's going to cost me and I'm going to give it to this managed care organization and you are responsible for all aspects of the program. So back to your question about a state doesn't have the resources to manage it. That's generally what occurs because it will say is the state's on the hook if it's the other type, right? They don't know what the claims are going to be and they don't know how much manpower is going to have to go into that to administer that program, take in the claims, do the adjudication, pay it back out. But in addition to that and in Medicaid program, a lot of times people don't have some of the things that other people might have, which is like a ride to the office. Maybe they don't have a good setup to receive information. What not what have you? Maybe they speak a language that the doctor doesn't speak or that the state has a difficult time finding a translator, whatever, whatever, what have you. When they go to manage care, all these things are built into the program. So the state pays a flat amount every month per member, a flat fee. So for arguments, say, call it 10 bucks, that's not, I just pulled that out of a hat. So let's say you get $10 a member of that that is on Medicaid, but you are responsible to make sure that a certain percentage of those members are utilizing their dental benefit. You are also responsible to make sure that for a child population that those, the utilization includes things like how many dental visits they have. Did they have a fluoride treatment? Did they have a carrier risk assessment? All these sorts of like heatest measures, which is the measures that we use, the sealants, that they have sealants placed. So the state puts these metrics in the contract and then the managed care company is responsible for hitting those metrics. And when they don't hit it, they pay a hefty fine for every member. If there is other things like I mentioned, like getting a ride to the doctor to the dentist, that's on the managed care company, finding a translator on the managed care company, calling the dental office and saying, hey, Dr. Casey, just assuring, I want to find out for sure that you are open to on these days that you said from this time and your contract says you need to be available for these times. This is what you said. What type of appointments you can take, what language you speak in the office, all these things fall under a managed care organization and all that falls in that $10 per member per month. Okay. Fall so far. Yep. Okay. So that's kind of like the bar right there. Now there's a lot of talk that comes out about, you know, in the industry, the dental loss ratio. People saying that, well, these dental insurance companies, they're just keep there. They're not paying my claim because they want to keep the money. They don't want to pay it out. Well, there's guard rails against that in a managed care program. So generally a state will set that around like 86, 87% dental loss ratio. That means that 87 cents of every dollar you get paid, how's it going to direct claims payment for dental treatment? If you fall below that, you get that money back to the state. So there's nothing there that says you keep the money because you're going to benefit. You have to give that money back. So part of that program is to when you put this on a managed care organization, you say, we're requiring you to do all these things that it spoke about. But in addition to that, we need to make sure that you're doing other things. You're responsible for monitoring fraud. So if there's any, you have to have these things set in place. You have to hire fraud investigators that are qualified and there's certain things they have to reach and they have to hit. You're required to do audits. You're required to monitor utilization to look at how many of a code is being performed and is that medically necessary? Are these members getting the right treatment? But also are we spending our taxpayer dollars the right way? And so when you combine all that stuff, the bottom line is you're looking for quality, access and cost containment, right? But not cost containment and trying to stop care. You're trying to make sure care happens because remember if you don't hit those metrics, you give money back because you get fined. So when people understand that, it's kind of a lot easier conversation to have. They understand what the guidelines are and what you have to do. Could you say as we continue this conversation, obviously your experience is going to be, your experience is going to be just in Nevada. So two part question, what is your formal title and then is what we're going to talk about as you kind of educate me on this? Is the structure of all of these rules that you just laid out because I'm going to learn all this? Is this relevant just to mostly the state of Nevada and it's really different across the rest of the country? Or does the federal government kind of lay it out so that Missouri and Nevada and Minnesota and Montana, all the different states have relatively the same principle so that if listeners and other states outside of Nevada, listen to this, you know, some of these principles you're talking about are likely found in those same states. Yeah. So great question. So the basic rules are the same. Number one, number two, my clinical experience is almost exclusively in Nevada, although I'm caliphany license and I practice in California as well. But my career managed care is spans across all countries. So I was, you know, I started out as a state down on director. I rose to Chief Dental Officer and vice president of quality management for my first organization. My current role is the Chief Dental Officer and vice president of network for Dental Quest and also for sunlight, the parent company of Dental Quest. The company I'm in right now at Dental Quest is the largest managed care dental organization in the country. We currently manage the oversight of Medicaid members for 24 24 25 million people across the United States. We have arrangements with over 110 health plans. We have direct to state contracts also with some different nuance I can touch on in just a minute. But we also have a commercial side, which is sunlight. And I'm so I manage I oversee the network teams for both Dental Quest and sunlight. So we have a commercial sunlight, which is PPO's and some of the private insurance contracts. And then we have an extremely large bank of government Medicaid contracts. We also have Medicare vantage contracts with people that know a lot about how that works and exchange products as well. So back to your question what we let into this is is it is a different state by state. Well, it depends on what the state goals are. So if you're in a state that that is in one, the rules are essentially the same, but each state has different budgets, different leaderships, some sense depends who's what parties in office and what the state is leaning towards and what they want to do. Right now. We're in a moment where there's that's a tight crunch on health plants across the country That's just that's just the facts the way the economy is and and and and the The health sectors getting squeezed dinosaur getting squeezed so our health plans when health plans get squeezed dental plans get squeezed So it doesn't mean that we're holding back care But it means that states will say I may want to move to a managed care model because I know what my cost is going to be now You're responsible so go manage this do all those things we talked about But then make sure you keep in people happy you have quality outcomes build these relationships Make sure that the care is medically necessary Make sure that the patients are being treated the right way make sure the dentist are happy Make sure you have enough access in every county that we operate in and go you know And that's kind of like we're at right now, but generally the rules are the same At the core standard with what you know where it starts. This doesn't matter per state. It just depends on time program the state does Is that like What about the states where Medicare or excuse me? What about the states where Medicaid is generally Kind of frowned upon by most the dentists in the state I'm thinking of Illinois for example, which is close to me Almost impossible to find a dentist a pediatric dentist even that's in network with Illinois You can probably count them on one hand in the entire state I don't know if they participate with denocuest as a managed care provider for Medicaid But you know, it's interesting you've talked about and I didn't know that that a certain percentage You know met the these managed care organizations have Like a legal duty to make sure that all the citizens that qualify for Medicaid have actual access to care So is it is it pretty common where some of these states where not a lot of people are seeing Medicaid Where those MCOs are getting penalized because they're not actually even though they say our members have Medicaid If no dentists are actually signing up because the reimbursement sucks You know is it is that I guess are you finding that a lot of states are having to raise fees and be more competitive to keep Dentist in network and seeing patients with Medicaid Or is it is it pretty common that you know MCOs get penalized for not you know giving the access that they're supposed to be giving Yeah, so a lot a lot of things in that question So like you brought up Illinois we are in Illinois and we do meet access standards in Illinois So really regardless of like yeah, so anecdotally you think whether or not people are are participants They are participating and we have we have a strong network in Illinois Illinois is a state that has what's called a carve out model. So we have contracts with Health plans so there are a number of health plans to operate in the state of Illinois So they get the $10 and then they my example $10 whatever and then they carve out a certain amount and say this goes to the dental company To run the program so I didn't mean to get us even more complicated But that's kind of the situation in a lot of states is it's not directly with the state in some states New York's like that Illinois is like that Iowa on the other hand is is a carve out So it goes to dental plans and so currently our my organization denacquist it just won a contract in Iowa So now we'll be entering into that state along with Delta Dell So they split it between two contracts But to answer your question are we do we struggle with that well? You're always recruiting right and you're always trying to go out and and find dentists that are willing to participate So we have a whole team that you know tries to work with the dentist. So we call them provider partners They're part of our provider engagement team which is the team that part part of the team that I oversee at denacquist in sunlight When it comes to fee negotiations if it's a straight Contract with the state so the I'll give you an example. It's like the the state of California That managed care only exists in Sacramento County and Los Angeles County. It's mandated in Sacramento County It's optional in Los Angeles County the rest of the state so 13 million people so maybe two million are in managed care 13 million people are under direct fee for service So when you're in a direct fee for service you can't you are not allowed to negotiate fees They pay you what they pay you So so if you were to go to the states that I want to I want to raise my fee on sales so crown They you not a level. It's really that's that's rules right But if it's a managed care company there managed care company has to pay at least what the state Medicaid fee schedule says they can't pay under that but they can go over it So then what what happens when we get approached and someone says my fees are low and you know I'd like to talk about raising them. Well, what we have to do is look We want to have those conversations. We want to we want to keep the dentist happy But we ought to look at where we're at because if it comes out of If more goes to you it comes it could come out of somebody else's pocket right there's only a set amount that can be spent People think that these that managed care dental organizations are just like just taking money handover fists You know, hopefully with example I told you like that dental loss risk are not allowed to and oftentimes You know if it's 87 as a floor oftentimes you find yourself operating in the hot in the mid 90s to try to be because there There's a lot of care that's going out a lot of utilization and we provide that care So it's not you know that leaves you 5% 5 cents in the dollar to do all of your administrative care So it's not that the fees you know, we're always open to discussing like hey, I you know, I want to want to talk to about certain fees Whether or not you get exactly what you want depends on number of factors. Do we have other dentists in the area that are taking our fees Are willing to see the patients? Yeah, do we have do we have access kind of patients get care It's not that it's it's not an attempt to create a wall or division between the organization and the dentist And that's something I take a lot of pride in that's something that that's kind of one of my soap boxes that I stand on is that look At my company at dental quest we're trying to move away from this adversarial relationship and say like Let us tell you what we're doing. We will be transparent about it We want to be an ally and try to help things go smoother for you. Can we always give you what you what you're asking for? No, we can't when we can try Right and and we try to let you understand what we're doing and why we're doing it and trying to build relationships with the dentist because These are my friends and colleagues and all the people on my team on my clinical team at dental quest and some life They're also the dentists the clinicians right there dentist said either practice part-time or used to practice full-time or still Still do some of them these are the people that are reviewing your claims when they come in these are the people that are state dental directors that are helping Maybe identify what the benefits are and interpret that for for their colleagues Um Then we have a non-clinical team a provider partner so the people that visit your office and say how are things going? You need help with anything and you help with the claim The goal is to create like this partnership because this it We need the industry to help pay for things and know people say like I don't you know I don't I don't need the son of one take this Well if we're talking about just Medicaid You have to like there It won't go away like we are funding care for people who can't afford to get it for their children And then we are as an organization like dentist we are required to take that $100 and spread it around all of the children in the state of Missouri right to make sure that there's enough to go around for everybody And then we still need that margin to be able to operate and run our organization for those things I told you about those things like Making sure that there's car rides making sure you're managing utilization making sure that there's no turpiter making sure Children are getting sealants these are all things there's a ton of people that go into this that try to make this happen So I you know I've been involved in some fee negotiations and try to be really transparent try to be honest and and just say hey Here's what we're looking at you know, I'm not pulling no punches here And we try to meet providers where they're at usually we'll try to We don't always land on what everybody wants We try to get them something to say look we don't want you to leave the network We value you we want you to be a partner in this We just we just can't meet where you're at or maybe sometimes we'll say we can right so it depends on the situation and the environment and the area that you live How that fee negotiation piece works. Yeah, that's a great answer Todd. This is this is great. So Let's finish that question and then I want to move on to what your day to day looks like because it you know I'm gonna learn so much in our conversation and it's obvious that you have a level of knowledge That's insane on this this topic But you know, I try to keep this to actionable things that in the trenches pediatric dentist that own practices that try to see Medicaid to help kids out But you know face a lot of the common struggles by trying to make it profitable as overhead keeps you know as or every year Rank goes up and you know supplies go up and everything and I feel like that's the big Achilles Achilles heel of dentistry is our fee schedules are pretty fixed and our pricing structure is hard to To adjust upward So my question is if if a dentist comes to you and makes a strong case like hey, I'm I'm a Medicaid provider I'm in a more rural area or less competitive area. I'm the only one see in Medicaid But I haven't my fees you know are have been at the state set level fees for six years I really could use a little bump and they say like here's my top 30 codes or something You know or or something along that line they reach out to their local Denna quest representative What is the process look like if if somebody comes to you and makes a request and is a very reasonable person tries to keep this a mutually beneficial relationship, which I think to your point is awesome Is it do you guys have like little committees or subcommittees that get together To kind of discuss and brainstorm like as you said that dollar has to come from somewhere else But what is the internal process look like as you try to like work out these fee schedules to keep everybody happy and and keep keep providers in network and that sort of thing Yeah, we try to balance it like with what you said like you said if somebody comes in their rural area where it's an underserved county And they say look you know, I'm really I'm struggling. I need it. I need to bump in my and my fees here the fees But that's first question asked what are you looking for send us send us you know send us the codes that you're looking at and And then we'll do an analysis and it will be our provider partner at that level and they'll work with their senior manager in that area And they'll create the grid and they'll say here here's the fees. They're asking for This price because oftentimes they don't put a percentage. So we'll calculate like well what that percentage is and what that looks like over. We have a store of claims. So we'll say like what was the, you know, what was it last year? How much is it gonna take out of the system that we're allowed to pay other people, right? And then we'll try to find something that says, like we want you here, either we're gonna meet what you put in there or we're gonna come back and say look, we can't give you, you know, a 187% increase, but we can do this. And no, we get that. We get something that says that it's 250 or 300% increase in certain codes. We just can't do that. You know, like, no, I mean, I wish we could. I wish I could say yes to everybody. But the time when it escalates to me is when it's gotten to a point where they've gone back and forth and they might say, hey, you know, can you reach out to this provider and speak with them and, but we have a really good team that does this on the level. And we generally don't have to escalate too much higher. At the end of the day, though, we do have to run through, you know, a financial committee to discuss it this and to say like, this is the impact it's gonna be. This is how it's gonna affect the market. There are a lot of things involved because again, we have to manage that dollar for the entire state. And so we're very careful about it. It's not just like a flippant thing. Yeah, I'm gonna give that to you or no, you don't get it. We take the time to take the response in. We communicate with them or provider partners who are out there, they're emailing, they're visiting, they're phone calling, they're doing Zoom meetings like this. And then if need be, we, you know, we ask, we go higher. And we generally, we come to an agreement. We try to get people. And oftentimes, Casey, we can't, you know, and if it's me, I'll say flat out and so we're all team. I go, look, we can't do it right now. It doesn't, we won't be able to do it eventually, right? Like if it's like, let's, we'll give you this and we'll see where we land down the road. We want you to stay in the program. You're vitally important. These children need you or adults, right? 'Cause there's adult coverage too in certain states. So, you know, we wanna keep you there, but we see that there's a need in your county. So, you know, we wanna give you this. We wanna make you happy and keep you in our network. So that's usually how it goes. - Yeah, so is it safe to say without putting words in your mouth? It's, you know, if somebody wanted to ask for, if somebody has never really looked at their fee schedules has been a Medicaid provider for a long time, it's not a bad idea, you know, putting yourself in the dentist shoes. Like, it's not an unreasonable to ask for a small, but modest, you know, maybe every couple of years, you know, reach out to your Medicaid, you know, contract or, you know, representative and say, maybe 5% or something every few years. There's something reasonable, like, would you advise that? Like, if you were a dentist practicing private practice in your 30s, trying to run a practice and see maybe half your practices Medicaid, would you advise that? Is that an okay thing? Like, yeah, 'cause I feel like a lot of dentists, I know, personally, that you and I know together that I'm not gonna talk about on air, have never tried to advocate for themselves, have never talked or sent an email to their representative, have never developed that relationship, have never asked for a fee increase. And I've had some luck getting bumps here and there, where it's not 187%, but like, maybe every couple years, I get a little three or four percent bump, which that makes such a big difference, just to not feel like you're behind every year. So, yeah, I don't know, I'm just trying to get out of you, like if you can kind of at least maybe encourage fellow pediatric dentists to kind of advocate for themselves and develop that relationship to try to just be common sense small bumps. - Yeah, I mean, and I have no problem with them doing, you know, I think that makes sense, in case, and I have no problem with that, and I oversee network for our company. So, if you guys are with Denacless, yeah, you can reach out. My team's probably gonna say like, why'd you tell a national group listening to this podcast, they're all reaching out all at once. - Yeah. - And maybe I won't be working here a week from now. Now, I'm getting an unpeeled position. But, you know, absolutely, like, again, go back to like, we want to be able to be helpful. And our team should be in their train to be understanding empathetic and be helpful in the situation. Yes, if you're a pediatric dentist and you want to, you feel like you need help, you can reach out. I can't guarantee it will happen, but we'll try. And we may be able to come back to you like you said. Maybe we'll give you 3% this year, maybe we can bump you later, maybe we can't, maybe we can't do anything right now, but maybe in a year from now or two years from now, you can get that bump. But you should communicate. You should be close to your provider partner. You know, cases at the end of this, I'm gonna give you my information and people can reach out to me whenever they want to. We have a team that are motto. And I've been in this role for one year now. I've worked to manage, except for 10, but I'm gonna make a little plug here from my company. Our president said, I want to make sure that we are a clinically directed organization because we serve dental clinicians. So I want the dentist to be in positions to say, here's what we need to do and here's why. Now we have an incredible team that is not dentist. So the executive level all the way down to people are answering their phones. So I'm not saying that. What I'm saying is, as a dental company, our president that came in newly in the past year said, this is what we're gonna do. And so he went out and he hired a chief dental officer and he put the chief dental officer in charge of the network, which is serving the providers. It's overseeing fraud, it's overseeing case management, which is making sure that people that have medical issues are getting the care they need, that they can get the extra care they need to get to the dentist or maybe to coordinate a visit with a doctor or maybe with a specialist. It's programs like going out to the community and giving out toothbrushes and helping people sign up for Medicaid. All of these things fall under the network team. The network team at Downacrest and some life is run by a dentist. So everybody knows that. So our model for the past year, what we've been establishing is, these are our colleagues. These are a lot of these folks are our friends. We are not against our fellow dentists. We are trying to be helpful. So yes, you can ask for that. We can't always do what you might want, but you can ask. And we wanna establish those relationships. Second piece, one of the things that we've done, we've cultivated this over the past year was, I mentioned earlier how we are mandated to monitor utilization. And we have a very experienced fraud waste and abuse team that's overseen by an attorney, a former attorney for state attorney general office. So lots of experience, knows what he's doing. He has a team of people that works for him. He's part of my team. We started in a new branch though this year and we call it clinical quality management at Downacrest. And what we do is we will look at utilization patterns that are maybe like let's say you and I and three other dentists all work within the same five mile radius in the same town. We will look at the utilization of those five dentists, but it's a lot more than five. Like it's gonna be a whole county. And we'll say, how come Dr. Gray does literally 10 times more stainless subcrowns than Dr. Casey, right? Or any of these other doctors in town. What we don't do is we don't look at that and go, oh, Dr. Gray's in trouble. What we do is we give that data to a dentist on our team who works, who has, whose license in that state, they look at it, they set up a call with the dentist and say, hey, this is not not it. This is not investigation. I'm calling to talk to you about the quality of your treatment. I'm required to do this. I want to hear about your practice patterns. I see that you are, you know, you're doing quite a few stainless steel crowns. I get it, you know, I understand the AP, APD guidelines because they all do. They're all trained to understand the guidelines of these different specialties. And we have specialists on staff. I just want to learn about your practice. Tell me what you're doing and why you're doing that and how you do that. So two things. We're establishing a relationship. We're learning why they do what they do. And we're saying, and if we see something that we will point out, state regulations say this though. So you, so, you know, yes, APD guidelines, we're not going to argue the stainless steel crowns going to last longer in a three year old than a DO on tooth L. The state regulations say you have to do least expensive alternative treatment. So if it's a small little cavity, show us why you had to do the stainless steel crown. Take a picture of the decal spication on the buckle. Show us where the lingua has like a little breakthrough decay. But if it's just like a little one millimeter into a dentin, according to regs and CMS and state, you can't put a stainless steel crown on that because it's going to take a stainless steel crown away from somebody else. But if you have a good reason for all you have to, we tell you document it. Put it in your notes. Tell us why you're doing it. We don't want to get you to get in trouble. We're trying to get out there and say, here's what we're doing. Here's what we see. How do we remedy this situation? Then we're going to monitor that. We're going to see how they change their practice patterns. And if they have great, we'll say, hey, awesome job. Thank you for working with us. There's more finances to go around for all the kids in the state now. If you have issues, the problems reach back out. If we don't see a change, though, that's when we step into that area of like, hey, look, we reached out. We're trying to be helpful. Please work on this or explain why you're doing it. Because if you don't, then it's going to go on a route where I can't help you anymore. So that's another thing that I say. I say, we are trying to create an ally relationship and not be the big bad insurance company that's insulting to me because I'm a pediatric dentist. And these are my colleagues and friends. Man, that's such-- It's so interesting to hear this perspective from you, too. But if you talk to-- you go to the bar with five other pediatric dentists that I'll take Medicaid. And you just-- everybody loves to complain and you hear these horror stories. And they came and audited me for this. And everybody just tells their horror story. But in my brief years of private practice, I just haven't had a really pretty positive experience with Medicaid. Once you learn the rules and the nuances, you understand that audits are a normal part of the process. You said this is a fairly low margin business for you guys. I think I maybe got one letter once a couple years ago that my percentage of stainless steel crowns was higher than pediatric dentists in my area. And I immediately called the phone number and explained to this really nice lady, I was rural pediatric dentist. I do lots of sedations on referrals and send kids back high-carriers risk kids. And she was like, oh, yeah, she was actually floored that a dentist called and was really nice to her. Because I was like, I want to explain myself. And I think she must be used to just getting her ass chewed all day or something. But she was really nice. She documented everything. I explained it to her. And I don't know. It was a much better conversation than I thought. And she just encouraged me. Like you said, good documentation seems to be the repeating theme here. But I haven't had the negative Medicaid experience that a lot of people seem to have with MCOs. And so I don't know if it's just me being fortunate or if maybe there's just old habits that die hard with the relationship people have with MCOs. I don't know. I mean, it could be right. So a couple of things. And that's a really good story. So your experience is how it should be, right? And you're probably practicing good pediatric dentistry and you're probably documenting what you do. And then you had a conversation. If you have a concern, reach out, have a conversation. But we've instituted this new program and we're getting ready to roll nationwide. We're reaching out to you ourselves, right? Now, I'm going to give-- because you said this, so I'm going to give a plug to a smaller size DSL group out of Arizona called Kids Dental Brands owned by Brent and Brad Roberts, wonderful dentist and Josh Arnold, either vice president. I sat down with him when I was in Phoenix way to meeting. And they told me, look, same thing you said. Look, we realized early on, there's no reason to create a dividing line and drag our feet in the sands with the MCOs. Why don't we-- instead, why don't we work together? And why don't we like-- we want to do good quality work. We want to do what the guidelines and regulations say. So they immediately said, we're going to establish these relationships. And we're going to have a good working relationship with these folks. So we have a line to them. We understand what they're asking. We don't want to be adversarial. And to me, when they said that, I was like, that's awesome, man. I love that. And they're a great practice. And they've done a wonderful job. But they're just one example of the same thing you said. They don't get on it. Because they're following what state regs say. But if you do, number one, the program I just told you about, that's not an audit process. That we just call those quality reviews. We're just checking audits. What happens if you don't-- if we see something, you can't defend it. Then it goes to a higher level. And that's where people get in trouble. But even then, they can get out of it. They can work with the auditor. And they can explain what they're doing. And they can change their ways. And hopefully, everything goes away. We want to avoid it before it gets there, though. Number two, you reached out and you communicated. And that's the big thing I'm trying to get across with this whole little ramble that I'm doing here. Communicate. Communicate with you, Rep. Call. Reach out. Say what's going on. Again, the goal here is not to try-- the people that are looking at your clinical work make no more money if you get slapped on the wrist. In fact, it makes more work for them. They're trying to be helpful. That's part of their job. They're trying to reach out. The goal is to not take money on your pocket or to get angry at you or to create an adversary relationship. The goals will work together so we can spread this money around. And so we can make sure-- keeps in the word money. We want to make sure the quality is there. And on our folks have been trained on what the quality guidelines are. And they know what the regulations are on the state. And then the regulations are at the federal level. That's the goal. That's it. But I wanted to ask you as now that you've been on both sides of the fence as a practicing pediatric dentist and now in your current position, which-- you've shed a lot of light like how big of a role you've had. I guess I didn't quite comprehend. I'd love to see what your day to day looks like with how big these meetings are with the scale that you're working with, DenneQuest here. But is there anything else that now that you've been in the industry has surprised you or things that are common misconceptions that you debunked in your mind, like things that most pediatric dentists think about Medicaid that you've found is wrong? I'm just trying to see if there's anything I missed as far as common misconceptions in Medicaid that are just not true or things that you might want to try to convey across to listeners, things that you've learned in your position that you didn't know when you were in private practice about MCOs. Yeah, I know. Absolutely. I think it's the number one is the concept of the big, nameless, faceless, evil corporation, right? The people that are working at NYUization, people like me, whether they're dentists or non-dentists, these are people that are so devoted to doing their work that if they work long hours, they work late into the night sometimes. And their goal is to try to make sure that they are getting at least in my company trying to get access to care and good outcomes for all the people that we cover. That's the bottom line. They're not jerks. They're not people that are trying to steal your money or make your life miserable. They're just hardworking individuals. And then flip side, the clinicians, they're dentists like you and I. And most of them practice and for whatever reason they decide they want to jump into this industry and learn more about it and take their skills they learn to clinical practice, maybe apply it on a different level. And that's what they are. So that'd be kind of the first thing I would say, Casey. The second thing I think, and I think this is big right now, is there's a lot of articles about a dental loss ratio, which we touched on earlier where people are saying we need more transparency. We need a dental loss ratio. We need you guys are keeping our money. And I think I already covered that. It's just not allowable. If you don't spend a certain amount on the actual treatment, you don't get to keep that money. You give it back to the program. Third thing would be I learned about all of the ins and outs of what are required to run a Medicaid or a private, we've been focusing mostly on Medicaid and that's fine. But also on the commercial side completely, completely different, but to run a program like that. There's many cogs in the system that have to be running smoothly to get the end result. It's not as simple as what people think. You simply claim to get it paid. There's lots of rules and regulations. There's a lot of people working hard on that. There's appeals. There's complaints and grievances. There's access and availability standards. There's making sure that the dentists that say they're available are available. We can see the shopper calls, for example, from clients that will call your office and say, "Hey, I'm a patient of, I'm covered by dentists. Are you taking appointments?" If you say no, we get fined. There are things like that that I had no idea about that had happened. I didn't know about the car rides. I didn't know about the interpreters. I didn't know about all of the outreach care that these organizations like mine give to the communities. Not just money, like to fund programs, but going to events. I'm on the board of a group called TeamSmile, which partners with professional sports organizations to provide free care for children all across the country. In your area, the chiefs are involved in the royals. We bring in volunteers. Organization that denoclasts in Sun Life is a big sponsor of TeamSmiles to try to get more care for people that don't have a dentist. All programs that we work with vendor groups and other folks that work with us, tell dentistry programs like Teledenture.com who we work with, who's a wonderful company that provides 24/7 service. All of these programs are involved. I had no idea about what went into it and how it happens. It seems complicated. The fact is, everybody there is working for the same outcome. Get people care, make a quality. Honestly, part of the quadruple aim is to make the dentist happy and let them have a good experience and our team is devoted to that. One of the final questions I wanted to pin on you and I was curious to see your response here. Let's say we had a time machine and we were going to take Todd Gray back to you're now 20, 29 years old and you're coming out of Iowa residency as a new resident and you're going to go set up shop and rural Nevada or wherever in the country you decide to go for family reasons. You're going to start a practice. Today's day and age knowing the current environment and the economy and what the marketplace for pediatric dentistry is. How would you do it? I guess two-phase, would you start a practice? If so, would you participate in Medicaid or would you encourage pediatric dentists to participate in Medicaid? Would you say it depends on the state and the situation? Do you still generally believe that it's as a pediatric dentist, we kind of have the obligation to try to fill that role? I mean, perhaps I'm naive, but except a couple of things. I never asked for an increase in rates and then maybe this naivety. When it comes to how I set up, I wouldn't do it any differently. That's just me and each individual is different. I have a big tolerance for risk in my life and in things that I do. When I first got started the first six months, I was barely hanging on financially. After that, it started picking up and picking up. That's my personality. Would I encourage to see Medicaid patients? Absolutely. It doesn't mean you have to just open the floodgates. If you feel like you can't take all the Medicaid patients come your way, we have a program we tried to promote. It says take five. Take five a month or five a week or whatever you're going to do. Help out, especially as a pediatric dentist. Help out IDD population. Help out children with cerebral palsy. How about children with autism? Stay late if you have to. It pays dividends for how you feel as a human being. That's the biggest thing. If you're a pediatric dentist and you're starting out, you will do well financially. But just beyond, you will. You will do better than almost anybody in this country. So keep that in mind. It might take you while to get there for your resident and you come out and you join KC's practice and you say, "I want what KC has." Well, KC worked his ass off to get to where KC's at. He's going to take a while, but put the work in and you'll get there. Whatever route you choose, where you choose to join a DSO group. You know, like KC does. brand that I mentioned or whatever it is or where you choose to go hang your own shingle. Some past are meant for people summer for other, but do all those things, like be a good human being and help people out. And I always felt like I never thought I was going to do, you know, I did well, you know, from a financial standpoint where in my practice, I didn't know what I was going to. I didn't know if I was going to be paying my bills. But what my thought was like, I'm going to do the right thing. I'm going to take care of everybody that comes in the door. And that turned into a really, you know, a good business practice, right? It business did well. But, you know, I was told a long time ago when I was first starting out by PDE artist, now I was asking all kinds of questions as I was getting ready to start supernars. He said, "Just go in every day and treat people the right way. You'll figure it out. Treat people the right way. Do the right thing and that will pay dividends more than you know." So that, you know, that would be my advice and talk to a mentor, PDE artist, talk to your friends, get with them, help them out. I think I told you a story case in my first week in practice. I had this, young infant and pediatrician referred them because they had like a growth in their mouth and didn't know what it was. And I sat down and looked and I'm like, "I'm not sure I know what this is." And I was on my own. And so I said, "Hey, I'll be right back." Like, I had to go check another patient. I went in and I called Mike Cannellus. I go, "Hey, this is my doctor, and I'm looking at what is it." And he goes, "So it's an eruption sis." You know, just take like a 12-blade and pop it, and he'll drink it. I go, "Yeah, no, it's a eruption sis. Here, let me fix this for you." But I didn't have anybody there. So like, use people that have already done this. Use Casey, use me, like get some mentors, Sean Whalen, who's a friend of both of ours. He's mentored tons of young pediatric dentists. Do that, and you'll be just fine. We support each other, and we always need to. Yeah, dude, I feel like we didn't even, I don't feel like I scratched the edge of how in depth in this conversation I wanted to go. So we might have to do a second episode, sometime down the road, and title it like "Busting Common Medicaid Myths" or something. Because I feel like it's impressive because you kind of got your iron in a lot of fires here. Like, you were in private practice, and now your chief dental officer, dental quest, doing all these different things. But you and Sean actually got on my radar because you guys have been working on a supply company as well. And I've been kind of working with you guys kind of look at ordering some supplies. But give me the quick rundown before we sign off. Like, just give me the package deal about like this project you guys have been working on to help Dennis get lower supply costs on this conversation of finding ways to like stay profitable and see Medicaid and watch your finances here. But is that kind of where this came from? Or tell me more about this company you guys have been working on from your life side? Yeah, so basically. Now a great segue. So originally, Sean, I had the idea of, you know, we both see a tremendous high carries rate. And you know, where Sean's in Denver, I was in rural Nevada. Came home one day being, I can't believe these children's teeth are still in such bad shape and started thinking of ways like, what can we introduce? How can we, you know, that's what, what can we do on our part as pediatric dentists? Is there something else we can do? You know, so we so we've originally developed our our volatile toothpaste. And it's called smile SMIYL. And that was intended to we said, look, we, you know, it's all it hasn't some antimicrobial effects. It's pure zyletal water and a atmosphere, right? We thought we can tell us to people for infants. We can put on a path of fire. So we just want to do something, something else. What we discovered was it really hit with a lot of our younger patients. And then we said, you know, what else can we do? And so we partnered with a company called Medi Denta and their base on a Las Vegas. Sean had been using them to order all his supplies. I started using Medi Denta because their their costs were so much lower than what I was using. Before example, I was giving us, I was paying $9 for a burrow. I got it from 99 cents, the exact same burrow from Medi Denta. So Sean and I, Sean knew them further well. We reached out to them. So let's design a product, a line of for pediatric dentists. Sean will test all the products in his office. We'll, we'll create a non-flora, pro-fee pace, anti-flora pace. We'll do flour varnishes. We'll do sealants. We'll do SDF. We'll do profy angles. We'll do everything we can come up with. And we want to make it price friendly for pediatric dentists. So the lowest possible margin that we can do, will you guys do this? And Medi Denta has been great. And I absolutely. So Sean, I've been working with their team for a little over a year. We just launched leading into the APD. And in fact, we had a booth there with Medi Denta. And our company's called Smile SMIWIL. So you're going to do smile.com. And it will drive you to the order from our site or to look what we have. And we offer pretty much everything a pediatric dentist could need. And we keep bringing more skews onto the product. We're going to smile brands SMIWIL brands, BRANs, ANDS.com bringing to the same website. Again, the goal was, originally was, what can we do to maybe help impenso slow down the carries right now. We, we shipped into what can we do to help our pediatric dentists colleagues because we know cost a rising. And so the good folks at Medi Denta have been great to us. You know, Smile Brands has been awesome. We just kicked off. We've made a lot of contacts. We have a lot of pediatric dentists that are reaching out. And there's one in and no more about our products and how they can get them and what the pricing is. So, you know, we always tell people, we'll be at any pressure pain and we'll get it to you. And we have top of the line products and ingredients. So that's what we're doing. We're excited about it. And hopefully we'll hear from everybody. Yeah. I was going to comment that met the Medi Denta partnership seems like a smart one. And I kind of encourage docs to check out their hand pieces, which I've been using their hand pieces for a long time, just because they, I don't know if you've tried out some of their hand pieces. And they've got, they've got some cool products like their hand pieces. You can get like a really high quality high speed handpiece from Medi Denta for like 500 to 700 dollars like equivalent to the K-Lers or the really nice ones. And I've I've enjoyed like their customer service has been good. So I've used Medi Denta. So that was cool when I saw that like I could, you know, kind of work with you guys to get profy supplies a lot cheaper in bulk. And then you know, you guys partnering them seem like a good partnership. So I feel like between you. And then I know I got to do a podcast again. Sean was on the podcast several years ago. And it was a really, really good episode. But he would be a good one to talk about. I feel like that dude's got so many different projects going like if he's not starting a, he literally starts a residency program on a whim. Like, you know, it starts a supply company. Like if anybody, like he's one of the most go get her hard work and dudes like that guy's an incredible pediatric dentist in human being. So I know if he gets behind something like this, it's going to be a project that hits and and changes things in a big way. So I'm excited to kind of see that. But yeah, I encourage listeners to check, check that out. Do you have a, what was the way? Is it smile.com if they want to try to order some supplies? Oh my God. SMIYLSmile.com should direct you to our smile brands website. And yeah, it case like you said, hand pieces, all those things. The cool thing about his Sean's op, Sean, Sean owns three offices in the Denver area. In addition to everything else you said and one of my closest friends, we met as residents. We both went to the downskill and I was well. But yeah, part of what we do with this company is Sean test products out. He makes sure that children is all he's a huge practice. He makes sure they like the taste, the flavor, all these things. He tries him out before we go live. Same with we're doing some hand pieces now. Also that many dentists have had Sean test out. We're doing Zirconia crowns that that Sean has been using on his patients. Right. So again, I agree with you. Sean's one of the hardest working, funniest. But one of the best pediatric dentists that I know and one of the kindest people, although you know, he has such an awesome sense of humor. People don't see that he's actually has done so much good for so many kids and people in his life. And I'm just I'm really grateful to have him as a friend and a partner in this in this business line as well. That's awesome. Todd, I feel like, you know, again, we'll have to do around to sometime. There's a lot that I feel like I didn't get to and I almost feel like I didn't do this justice. But hopefully we scratch the surface to provide a little context and insight on the inner workings of working at DenaQuest and appreciate the time. As we sign off, let's leave us if anybody wants to get in touch with you with some specific questions from something. Listen, is there any way people can contact you or email you to kind of follow up if somebody wanted to talk to you in person potentially? Yeah, I'm going to give my email out my work email and and and listeners can can email me and I will respond. And if I get just a ton of emails, it might take me a minute to get to them, but I absolutely respond. So it's just my name. It's Todd to T O D D dot gray g R A Y at great gr e at dental plans dot com Todd Gray at great dental plans dot com. That's my dental quest email. Happy to connect with any pediatric dentist or any other listeners that you have out there. You know, send me an email and if you have questions and if you know if I don't have the answer or I thought my head, I'll find it for you. Let's you know, let's let's work on establishing, you know, good relationships where we can help each other out. We're not dental quest is not out to get anybody and I want to destroy that myth. You know, reach out to me. I'll help you out if I can. Happy to do that. Love to do that. Love it. All right, Todd. Yeah, thanks for making it happen. I appreciate you working through my internet and and bad storm issues and stuff, but I think listeners are going to enjoy our conversation here. So appreciate making it happen and having a late night beverage with me, man. It was great. Yeah, thank you, Kasey. All right. Good time. Let's do it again. Thank you. Have a good evening. Sounds good. Yep. Thanks for listening to the Bruce and Tiny Teeth podcast. Be sure to DM our host, Kasey Gats on social media with any listener questions, comments, or tough clinical situations. We'll see you next week for another unfiltered episode.