Fees Fees Fees!

04/24/2013 by Dino C

FEES FEES FEES! Is it the price, or the VALUE?

There's been a lot of talk about fees lately so of course I'll give my 2 cents!

When I started my practice 20 years ago there was one other practitioner in town. I opened my own place with no patients and basically charged the same fee (maybe slightly lower, can't remember) as the other Orthodontist in town, which compared to surrounding cities was average or slightly lower than them.

About 3 years later, I bought the existing Orthodontist's practice and until about 3-4 years ago was the only Orthodontic practice in town.

From DAY 1 all I ever read or heard from consultants, accountants, etc, was to automatically raise fees 3% or more each year. They constantly pushed the math which says you can raise fees x amount, and lose x plus y number of patients and still make more money with less patients to worry about!

I never signed on to this. As the only one in town for 15+ years, I didn't want to give anyone a reason to go out of town to get their treatment. As towns around me were raising fees, I kept a lean, mean operation with excellent treatment and customer service, a great facility that has been updated several times, at an excellent price. Not super low by any means but definitely average or below average for my state.

Now, fees are really a very personal thing. And if one's philosophy is to charge high fees I HAVE NO PROBLEM WITH THAT WHATSOEVER!

My philosophy for average to low fees revolves around my statement above plus:

Market/Market Share- not only do I want to expand my market share (the pool of ortho patients looking for a provider), I also want to expand the Market itself (any patient who can benefit from orthodontic treatment). I feel by keeping fees "affordable," many patients who would never have thought of getting treatment done can consider it because it is not prohibitive to them. I feel I have really succeeded in my area in increasing the Market, not just Market Share.

Competition- When Dentists providing ortho or other Orthodontists coming into the area consider competing with my office, they need to consider not only our excellent customer service and hi-tech facility, but they have to consider our low fee as well. Sure they can try the "charge more" perception of higher value but once patients come into our office they see the extremely high value we already provide at a super-reasonable fee. That's tough to compete against.

The "sleep at night" philosophy- again this is a personal thing. I feel I have a pretty easy gig. Yes as a business owner with staff issues, business debt, etc, it's not the easiest job in the world but in general it's a pretty nice lifestyle. In fact, I wouldn't trade it for most any career I can think of! So I feel better (probably a rationalization, I know) when I know that in my community I'm not pushing the top limit of price point all the time.

I think the most important point in setting your fee is that you need to create VALUE. If your fee is high, you need to make sure the value is there to warrant the higher fees. The value can be in the form of excellent treatment results, great customer service, facility amenities (coffee, ipads, etc.). But this value isn't worth a thing unless you can properly communicate it to your patients.

Ok that's long-winded enough!
Comments welcome!

Nickel and Dimin'

I really don't like being "nickel and dimed" and I guess that probably shows in my practice philosophy.

For instance, since DAY 1 in my practice (20 years ago I hung my shingle and started from scratch), I have never charged for records, radiographs, recall exams, initial exams, extended treatment, broken brackets, replacing or repairing a wire on a visiting out of town Ortho patient, and many more items. Do I think it's wrong to charge for those things?   NO. Believe me, I've listened to many consultants, etc, who told me my time is too valuable to be giving it away and patients need to be kept mindful of that value by being charged a fee.

In fact until about 5 years ago I didn't even charge for lost retainers unless the patient lost over 10 or so! You don't think that drove my staff crazy? I finally began a policy where patients would receive 2 free retainers if they lose them (or don't wear them so they don't fit anymore) and after that we charge $75 each. I still don't charge patients if they are just worn out. I figure if they wear them so well they're worn out I'll reward them by replacing them at no charge.

So, that certainly is a lot of lost income, right? And I'm probaby being taken advantage of quite often, right? Absolutely! I mean, our time IS VALUABLE and we shouldn't be giving away this stuff for free, RIGHT?

Well here's the way I look at it.

I'm a big ticket guy. I'm asking these families to pony up 5k for braces. And what I want is EVERY single person I come in contact with who needs and desires braces to pay me 5k for it. But I also want them to know that I appreciate them spending that kind of money for my services and I don't take it lightly. In fact, I want them to know that if they commit to spending that kind of money with me that I'll take care of them. I'll see them for recall for 4 years and 4 panoramic films and not charge them a thing. If they break several brackets I'll needle them and if it gets worse we'll have a chat with parents about extending treatment time, etc. But I don't charge them extra. And if they come in my office 10 years after debond and want a replacement retainers because they've worn them out I'll replace them at no charge.

Know why? What happens 10 years after your braces are off? Families get started, friends ask who that nice Orthodontist is, families of 6 come in for initial exams and records knowing that they won't be charged initially. Sisters move to town and have braces-age kids and get recommended to that "nice Orthodontist."

So for me, it's about selling the value of a five thousand dollar case to new patients, not supplementing income from existing ones. It's about Goodwill and the value that creates for your practice when your patients discuss you and your practice to others in the community. To me, that Goodwill has been priceless!

Comments welcome!

Rever$e Curve Archwire$

In my never ending battle to reduce overhead, I strive to keep my inventory down (see "Archwires" blog post for a more info on this). One great little technique to save supply costs is to put your own reverse curve in your archwires.

Items needed:

Archwire
Cotton Pliers
(is that simple or what?)

Just use the edge of the cotton plier handle (I tried regular ortho pliers but the handles are too rounded). Make sure you tweak it pretty good to permanently deform the wire, or else you will just temporarily deform it and the inherent memory of Nickel Titatium will work against you.

The video above is of me putting reverse curve in 2 archwires. The first is a 16x22 Thermal Nitinol, the second is a .018 Nitinol. It may take a few times to get the hang of it but after that it's pretty easy. When I first started this technique (Thanks for the tip Dr. Bellon!) I made sure to check if the wires "held" their shape and in fact they do if done correctly.

Besides saving money on expensive pre-curved archwires, this technique enables you to put more/less reverse curve, or unilateral reverse curve!

Good Luck!

Ok let's talk about software

***Long Post, entirely PERSONAL OPINION***

I remember I think it was around 2000 or so (don't hold me to that date) my brother and I were walking the AAO exhibition hall. OrthoTrac was the biggest vendor by far. I was kind of on the lookout for a new software program, and I was AMAZED at the amount of salespeople they had and square-footage they took up on the floor. There must have been 75 plus mini-consultations going on with Orthodontists, staff, salespeople, software demos, etc.

My brother said, "Wow. Maybe you should check them out. Everyone seems like they are signing up."

I said, "Those people are making a deal with the Devil!"

Now, I didn't really think OrthoTrac was the Devil. What I was getting at was one of my biggest pet peaves in life. I HATE BEING NICKEL AND DIMED!!!

When I buy a software program (or anything for that matter), sell me the whole thing for a fair price. Don't sell me the basic package for 30k then say:

"Oh you want the treatment card? 3k more."
"Oh you want imaging too? 5k"
"More than 2 workstations? 225/workstation"
"Animated cartoons with braces education? 1500"

At the time, I was using klunky old DOS Based Orthosoft. It was great and did pretty much everything for ONE PRICE! The only thing it didn't do (this was pre-email reminders, etc) was incorporate imaging.

With that in mind I hung on to Orthosoft for several more years, until finally taking the plunge and purchasing a new program. For me it was AOS (Advanced Orthodontic Systems).

So what follows are the features I'm happy with in AOS and some features I wish were better.

The Good:

1. Cloud Computing

This is the best feature of all. NO SERVERS TO DEAL WITH. So no EXPENSIVE server hardware, no networking software to have to continually upgrade, no daily backup tapes to worry about. Any old laptop can access the software from ANYWHERE. This is super-important because I don't have to constantly invest in faster, RAM hogging workstations. The software is run as a 'thin client' so it takes up very little memory and processing speed.

So the cloud computing feature alone has saved me tons of money already.

2. All Inclusive Package for One Fee (plus monthly subscription rate....)

Okay I couldn't get away from some other charges. I bought the software, which includes everything all of the other programs charge you extra for, for one very reasonable price.

I do have to pay a monthly fee, but this is mostly for licensing (from Microsoft, etc) but it also includes in it the yearly support fee, so I don't get hit with an annual fee of upwards of 3500 or more each year.

3. Small Company

This allows us to get quick answers from emails, phone calls get right through to tech support (or they return the call quickly). You don't have to fill out some "tech support case #2245-7" questionaire and wait for someone to respond.

Since it is a small company, we may miss out on some leading edge things (however we do have the ability to email all of our correspondence to GP's, Patients, etc), and there is the possibility that the company could close it's doors, but so far it seems to be clearly more of and advantage than a disadvantage.

4.  Has all the bells/whistles (mostly..)

Ability for multi doctor, multi locations (I have 2), can have patient check in/out. Good insurance tracking, recall tracking, etc.

Good appointment book, ability for doctor-time scheduling etc.

Here are some negatives:

1. No Seamless Imaging Integration

I currently use VixWin for my imaging program. AOS has the ability to import images and radiographs into each patient file, but the process is time consuming, and although the AOS program is very fast over the internet, when images are added everything slooooows dooown.

It would be nice if they could get this worked out, but in the meantime I just have Vixwin opened seperately to access images, so not that big of an issue at this time.

2. No text message/email reminder system

Don't get me wrong, AOS and Televox have provided me a pretty seamless integration for this feature, so all my patients who opt in are sent text/email reminders.

I just don't see why it can't be done with AOS only. It seems like a pretty easy feature to add, and I wouldn't have to pay 2 companies to get it done!

3. Steeper Than Average Learning Curve

Like most software programs, AOS has some aspects that are just counter-intuitive. Some of the reports, accounting and insurance set-ups, etc, took awhile to get figured out. We do fine now (bought the program in 2009), but it took awhile.

4. Not very "Sexy"

Since it's a small company with a relatively small number of users (I don't know how many), I can't go to their big booth at the AAO and get first class treatment and talk it up with all the other users. Of course this isn't a huge deal since I'd much rather save tons of $ every year, but it would be nice if maybe they would create a user's group or interactive portion of their website (which is somewhat outdated) so that Users can share information and ideas.

Okay that's about it. Whew!

As always, comments are welcome!

Chairside Efficiency!

Broken brackets, emergencies, late patients, afternoon rush..... what to do? Is every afternoon an exercise in triage? What are we getting done here?

In order to control overhead, it is absolutely critical to keep patient treatment times on track. In our office over 80% of our patients are treated in 14-18 months. This is the single most important aspect of overhead control. More patients that are in treatment cause more emergencies, more hygiene problems, more missed appointments, etc, that drag down your bottom line.

So the strategy I use is to use EVERY appointment to get the most treatment done to further the goal of finishing in the short amount of time.

Example one:

Patient comes in with LR6 off, she's wearing elastics. We are busy but not slammed. Her appointment is in 4 weeks. My assistants rarely even ask anymore. Just get the tooth ready and let's put the bracket back on. Yes I know we're busy and a wire clip would take 30 seconds while a rebond in this case about 10 minutes. But I want to get her done! I don't want to delay treatment another month. We already had to get a chair ready, etc., and she's here now so let's do it! (not yelling just excited)

Example two:

Patient has a wire poking badly and needs to come in. Goes to school 20 miles away (happens a lot in my area). We are very busy. No broken brackets. It's on the schedule for "emergency 10," so 10 minutes are allotted. At this point we will do the entire adjustment, even though we are very busy. Reasons? Again, they are already in your chair. Also, if you do the ADJ appt now, it frees up another appointment when they were due to come in (possibly opening up one for an EXAM). Finally, the parent is super happy that you just saved them another 40 mile roundtrip visit and time out of school in 1 week.

Now, you may think these examples are obvious. But actually you'd be surprised how many emergencies are treated quickly with no one knowing when the next appt is scheduled, where the patient is arriving from, or where they are in there treatment.

The point here is to use every appointment to it's fullest.

This probably brings up issues in some minds like "well our policy is ____________."

Of course, I have an opinion on that too, so the next blog will address, "I'm sorry, that's our policy."

Stay Tuned!

Archwires!

How many types and styles of archwires do you use?

This can be an inventory/stocking/overhead nightmare! So my strategy is to both reduce supply overhead and increase treatment and office efficiency by reducing the types and styles of archwires I use.

Again, here's my 2 cents:

Upper/Lower Nitinol archforms:

 Don't order both. Just order and use either upper or lower. I've always used just one type here. I just don't think it makes a difference with something as flexible as nitinol. Some may say that if you don't use both upper and lower that the teeth won't interdigitate or perhaps you can end up with a wider mandibular arch causing antererior/posterior crossbites, but I just haven't seen it clinically. Ever.

Ovoid/narrow/euro, etc.,:

Again only one shape used here. The alternative can be a real headache if you are trying to match each patient's natural arch form with your current stock. I always use a rounded, ovoid arch form. For everyone. Once we're into steel wires, if needed they can be reshaped to customize the arch better. But in nitinol for me, its ony one shape.
Sizes:

Of course this depends on your prescription so I'll just list my typical sequence (.018 Roth):
.012 Nitinol (Love this wire!)
.016 Nitinol
16x22 Thermal Nitinol or 17x25 Thermal Nitinol
16x22 SS (if needed)

Often nonextraction cases are debonded with U/L 17x25 Thermal Nitinols.

The goal is to use a prescription and treatment mechanics that utilize only a few wires. Some times I venture from this (I use .018 nitinol that I put my own reverse curve in, etc.), but again for the 70% of patients this is the norm.

Consider the effect on overhead: the bulk of my wire orders are 4 wires. Contrast this with someone who typically uses 6 wires x U/L x 2 or 3 arch forms and all of the sudden you are stocking 24 different wire types and sizes rather than 4. That alone is an overhead burner and labor/charting/inventory intensive.

Bonding vs. Bending

I typically don't bend wires. I have several rebonds during treatment, so once the brackets are exactly where I want them the wires usually don't need any bends. Now, if I have a patient scheduled for a debond the next appointment and #8 is tipped slightly lingual then I will put a quick bend if for something like that.

This strategy can be a tricky one in an effort to control overhead. I will definitely go through more brackets and thus more overhead with bonding instead of bending. However I feel that my clinical efficiency is improved and treatment time reduced such that it makes up for it. Also, since the brackets are now so inexpensive (blatant commercial see www.cxorthosupply.com), I feel the impact on overhead isn't as great.

Well that's it for archwires!

As always, comments are welcome!

Dr C

BT's: what are they good for?

So are there any of you that consistently use BT's on patients? If you already are very familiar with them this blog may not be too useful but I hope you enjoy it anyway. As always, comments are welcome!

At our office, BT is an alternate label for Bite Turbo. I'm not sure if that name is trademarked, so we've always just called them BT's.

BT's are additional amounts of bonding material we apply to selected areas to open the bite and guard against tooth bracket contact.

Here's the scoop:

Since I bond ALL TEETH, it's super important for us to limit broken brackets in order to, 1: reduce treatment time, 2: save chair time, 3: keep down emergencies, all resulting in 4: REDUCED overhead!

Although the obvious use is to guard against broken brackets, perhaps just as valuable (and possibly more so) is the desirable effects BT's can have on treating certain malocclusions. For example, if I have a 14yo patient with 100% overbite, I place BT's on the lingual of #8 and #9. If the laterals are lingually displaced (as in Class 2 Div 2) I'll place them lingual of #7 and #10.

By opening the bite, the occlusion and muscles of mastication are "disengaged" and extrusion of the premolars and molars occurs extremely fast. As you may know this very thing has been accomplished with Bite plane (or bite plate) retainers for years, however it's faster to apply and more predictable with BT's.

Alternatively, on a high-angle or open bite patient I generously apply BT's to the lower 1st molars. This of course opens their bite even more, but the added bite pressure on the lower molars is an intrusive force and can help you with your bite closing mechanics.

Here a few things to remember when using BT's:

1. Don't forget about them! If you are using class II elastics BT's that are still hanging around can interfere with your class II A-P correction. Also, they look pretty silly on retainer models or in hygienist's chairs! Some practitioners use a different color adhesive so that it easily identifiable during treatment and at debond.

2. Be careful to use bonding adhesive which does not have too heavy of filler that it can wear down opposing enamel!

3. Inform the patient and parent, especially adult patients, that their back teeth aren't going to touch for the first part of their treatment! I make sure adults know this is going to significantly reduce their time in appliances (which it does), because it's definitely not a comfortable bite for them in the beginning.

One final thing on BT's. Several companies sell instruments to help form and apply BT's. Also, metal BT's (official "Bite Turbos") are available also. I've just found adding the adhesive myself is the easiest, most inexpensive way to go. I usually just use extra adhesive flash from the brackets when I place them at the Full bonding appointment.

Well that's it for BT's! Another critical element I use in my practice to increase efficiency and reduce overhead!