You are 52, healthy, fit and at the peak of your career. Your practice
is well established and you enjoy the security of a good income, a group
of committed employees and financial security for yourself, your spouse
and your children. With most aspects of your life well in control, you can
afford the luxury of putting some focus on your own personal health—the
one thing that your practice cannot, per se, provide for you. You belong
to a fitness club, work with a personal trainer, do your regular aerobic
workout each day and generally feel as good as you have felt at any time
of your life. Nothing seems lacking and your life is abundant. On an unexpectedly
sunny spring day, you decide to take advantage of the warmth and go for a
bicycle ride rather than staying indoors and doing your typical stairmaster
workout. Water bottle filled, helmet securely fastened, you take off on one
of your favorite routes that will not only provide you with an hour of cardio-vascular
exercise, but will also swing you past the salt water inlet and through one
of the loveliest local parks. Life couldn’t be better. About halfway through
your ride, as you are contemplating your next vacation trip, a driver, unbeknownst
to you, reaches for something that has fallen onto the passenger side floor
of his car. In doing so, his eyes are diverted from the road and in the
moments that it takes him to reach the item, he swerves into the oncoming
lane of traffic. When he looks up, he sees a car bearing down on him and
he instinctively pulls the wheel hard to his right to avoid the collision.
The driver loses control of his vehicle, which plows straight ahead toward
the curb, passing through the clearly marked bicycle lane and, in the process,
runs over you and your bike. The good news is that the final thoughts of
your life were positive and you “went out on top.” The bad news is that
your life is suddenly over, leaving behind a widow and children, all of
whom may be well taken care of by your insurance policies, assuming you made
time to secure them. Also left behind are your practice, your employees and
your hundreds of patients whose fate is far less clear than your family.
What insurance policy will handle this major part of your life? Which insurance
policy will maintain your loyal employees’ workplace? Did you take out a
policy that will guarantee that the patients who trusted you will have continuity
of that care? For many dentists, these are considerations that may never
fully reach the level of conscious thought that they deserve. Few of us expect
to be a bicycle accident victim at the peak of our lives, yet the story above
is a slightly fictionalized version of an actual event that happened to a
local dentist in my community. This is not the only possible story, either.
I can relate from my personal experience the stories of others: the dentist
whose car slid off a curve in the road, plunging him to his premature death,
or the stories of actual friends who have endured by-pass surgery, cancer
or heart problems that fortunately did not end their lives, but did put them
out of their workplace for extended periods of time. These are all situations
that have occurred to real people whom I have known. In two of the cases,
their worries about the fate of their practices were minimal, for they had
secured the cheapest insurance possible—membership in a mutual aid group.
This is the best insurance and peace of mind that is obtainable because such
a group can maintain a practice in the absence of its owner so that when
the afflicted doctor is ready to return, his office is there for him.
Why a Mutual Aid Group?
My definition of a mutual aid group is: several like-minded professionals
who are committed to each other to maintain the viability and economic
health of an office whose owner is disabled or dies. Although I have never
read or heard any hard data on the topic, I would guess that an absence
from an office for two or more months might have a significant impact on
its viability. Absences of greater duration have the potential for ending
the practice’s existence. Without a program for continuity of care for the
patients, how long can they reasonably be expected to wait for their needed
dental care? Overhead insurance may partially (or even fully) fund the office
overhead, but realistically, can employees be expected to sit idly collecting
paychecks with nothing to do all day long? My Team members become anxious
on days that we are not fully booked—I can hardly imagine how they would
fare with an empty appointment book facing them for months! In spite of their
loyalty to my practice and me I can’t help thinking there is a limit.
Mutual aid groups can take many forms and each one should be customized
to the needs and preferences of the participants. For the purpose of illustration,
I will cite in this article the elements of the mutual aid group to which
I belong. These are not necessarily intended as “the” guidelines, but rather
more tangible examples of how at least one group has done it. We have implemented
our assistance program two times in my 22 years of membership and not only
did both practices survive and continue forward into the future, the experience
was, for the most part, a very stimulating and educational experience for
everyone involved. The disabled doctors were tremendously grateful for
the support and the adequate time to heal from their infirmities so that
their return needed not be premature. For the doctors who went into the
practices, it was an opportunity to experience another way of doing things,
new materials and techniques and pick up (first hand) new tricks. For the
employees (and, ultimately the doctors) of the involved practices, it was
the clear realization of their value, since they, in essence, ran the office
as usual, but now found that the owner was an interchangeable part. This,
by the way, can be a very freeing realization for the doctor, too! Lastly,
patients were duly impressed that other doctors held the owner in such high
esteem that they would take time out of their practices to come to the aid
of a colleague. In short, nobody felt this was anything other than a remarkable
and positive experience!
How Does the Program Work?
Many variations exist, but it is my opinion that to be effective, a minimum
of 9-10 doctors should be involved. This number enables the group to provide
maximum support without crippling the practices of the doctors providing
coverage. A clear contract must be written that sets the guidelines for
the agreement. Included in this contract must be all of the following elements:
• Duration of coverage
• Definitions of disability
• Mechanics of coverage
• Any special stipulations
Duration of Coverage
It is vitally important to establish the exact period of time for which
the mutual aid group is legally and morally responsible for covering the
practice of the disabled or deceased member. It cannot be overstated that
sympathy, compassion or desire to help will compel a group to continue helping
beyond a point that is advisable. On the other hand, inconvenience, economics
and personal feelings might influence the group in the opposite direction.
By setting the guidelines early, it frees the group of any need to make decisions
or, more importantly, exceptions, to the coverage of a practice. It is
already established, in writing, so that everyone goes into the process
knowing just how long the agreement will be in place.
In my group, we have agreed to a maximum of six months of coverage, no
matter the situation. It is the collective opinion of our group that this
is an appropriate period of time for the practice to be sold, in the events
of death or permanent disability, or maintained to allow the temporarily
disabled doctor to return. It is less important for this guideline to be
established from this article or our group’s decision than it is for the
new group to discuss thoroughly the goals and needs of the mutual aid program
they are creating.
Definitions of disability
Perhaps no area of this agreement has more potential for creating misunderstandings
or problems than the definitions of disability. There are a variety of
ways to define disability, but the easiest way is to look at existing definitions
from insurance policies. These may vary, so conversation within your group
will be important. The elements we have included in our agreement are as
follows:
1. The doctor must be unable to perform the usual tasks
or procedures in his/her professional practice
2. The doctor is under supervision and the orders of
a physician
3. The doctor isn’t (or is, as the case may be) expected
to return to full-time practice
In addition to these definitions, we have further defined the degree
of disability (in the case of temporary) as follows:
1. If the doctor is unable to perform his/her regular
duties for more than 4 hours per day, the mutual aid group will provide full
coverage
2. If the doctor is able to perform his/her regular
duties for at least 4 hours per day, but not for a full week, coverage will
be provided only for the days on which he/she cannot be present
3. If the doctor is able to perform his/her duties
for at least 4 hours per day for an entire week, the group is not required
to provide coverage
In this way, there are no “gray zones” for coverage and the group has
clearly defined limits and obligations on covering for a disabled colleague.
Mechanics of coverage
It is my opinion that the mechanics of coverage must be meticulously
spelled out to insure proper aide to the disabled doctor. It is not uncommon
for a group to find that inconvenience becomes a factor in stepping forward
to work for the person in need of assistance. In our agreement, we have
a pre-established rotation that was determined by random draw so that everyone
signing the agreement understands exactly when his/her turn will come up.
That is, once the disabled doctor’s office has contacted the program administrator,
it becomes a simple process of assigning days based on the agreed-upon rotation
so that nobody can claim that it “wasn’t convenient” on a certain day. The
order of this rotation does not change, but each year it is changed by an
increment of doctors that will insure equal opportunity both at being first
in line as well as last.
The starting point of coverage is another item that must be carefully
defined. In our agreement, we felt that starting coverage three weeks after
the first day the member doctor misses is appropriate. The group also requires
a minimum of two weeks’ notice. In the instance that the doctor has been
expecting to be back “any time,” but misses two weeks before notifying the
group, the group would not be required to provide support until the start
of the fourth week (since it would be two weeks after the notification). This
is an important point to clarify, since the range in time may be deemed shorter
for some groups. Our feeling is that because each member would be canceling
patients at his/her own practice, it would be impractical to start less than
two weeks after notification. That gives the offices adequate time to reschedule
clients. Again, this is merely the guideline we have established, but need
not necessarily be embraced by any other group.
Last of all, the specific time expectations for the supporting doctors
to be in the disabled doctor’s office need to be established. When geography
creates a challenge for travel, the request may arise for shorter hours
at either the outset or the completion of the day to enable the traveling
doctor to commute back and forth. In our group, we have established a clear
boundary around that potential situation by defining the support as being
for the normal working hours of the practice receiving aid.
Any special stipulations
Any group considering a mutual aid agreement should include any special
stipulations, such as mutual aid for the circumstances of disability related
to alcohol or drug use or high-risk hobbies. In the former, for example,
we limit the coverage to a shorter period of time than six months and only
agree to provide aid if the individual is in a treatment program. In the latter,
it must be decided if coverage will be provided if the disability is related
(for example) to skydiving, mountain climbing or other hobbies inherently
dangerous. You may want to include stipulations about pregnancy (whether
it is covered or not) and any other situations that could arise out of unusual
circumstances.
Because our group has activated our agreement twice, we have learned
much about the potential pitfalls and have continued to create an agreement
that will foresee as many of these as possible. No document will be perfect,
but the more thought that has been put into the agreement, the higher likelihood
for success. While I don’t put much time or thought into considering my
own premature death or disability, I do enjoy enormous peace of mind knowing
that under those circumstances, my family, my practice, my clients and my
Team members will be supported in the best way I can imagine—through the
efforts of my trusted colleagues. I would never suggest that anyone reading
this article stop riding a bike, but I definitely recommend that at least
some thought be given to eventualities that could radically impact all the
people who are important to you. A mutual aid program is not only practical;
it is inexpensive and is the most profound peace-of-mind insurance you can
buy!