Do you attend a “quality dentist”, or a “quantity dentist”? Does your dentist take time to talk with you, build a relationship, and explain their care recommendations? Or does your dentist’s office feel like a hectic assembly line? Do you sense that your dentist recommends the minimum treatment necessary to provide good care? Or do you feel like, every time you visit your dentist, they recommend a new treatment?
Regardless of your dentist’s skill level, the business choices they make go a long way to determining the level of care you receive. And the choices you make as a consumer can heavily influence the care options available to you, and how much you pay for them.
To understand whether your dentist is focusing on quality or quantity, we met with Drs. Dino Gharibian and Angie Terzian of DNA Dental Studio. Drs. Dino and Angie outlined the challenges dentists face in building their practices, and how these can affect patient outcomes.
Dentists face two primary business challenges: Patient count and payment reliability.
Understanding “patient count”
The “rule of thumb” is that an established, successful dental practice will have between 1,800-2,000 patients under their care per dentist. On the surface, this may seem counter-intuitive, because it only gives a full-time dentist (40 hours per week, 50 weeks per year), one hour per patient each year.
According to Dr. Dino, “The 2000 model is simplistic, but accurate. Most practices have dental hygienists who pick up the slack for dentists. This allows the dentist to focus on big procedures while hygienists clean teeth. The dentist still sees the patients for their exam, X-rays, and to discuss their treatment.”
A major difference between dental practices is how they achieve a high patient count. One approach is to build a base of loyal, long-term patients, through referral. Another is to accept as wide a range of insurance plans as possible, building as wide a pool of prospective “in-network” clients as possible. This approach can speed growth, but also has significant downsides, as outlined later in this article.
Most dental offices take a blended approach, especially early in their development. They accept a range of insurance plans, and attempt to use them to build a loyal patient base. But this is a balancing act between new patient intake and patient loyalty, that not every practice gets right.
Understanding “payment reliability”
Dentists get paid in two primary ways: Up-front payments and insurance reimbursements. There are also emerging “membership models” of dental care, but these are relatively new and rare, and are beyond the scope of this article.
Up-front payments include cash or cash equivalent (e.g., credit card) payments. Insurance co-payments and deductibles are included in up-front payments, as they are paid directly to the dentist. The advantage of up-front payments is that dentist’s can collect them instantly. However, they are based on the patient’s ability to pay. Of course, easily available payment plans can greatly increase a patient’s ability to pay “up-front” – even if it saddles patients with long-term payments.
Insurance reimbursements are paid after the fact. The dentist provides the care, submits a claim to the insurance company, and, all going well, gets paid for the services they provide. The advantage of insurance reimbursements is that accepting insurance policies gives them access to a wider pool of prospective patients, and patients do not have to pay the full cost of treatment, up front.
Unfortunately for dentists, reimbursement rates for treatments vary widely between insurance types, especially HMOs and PPOs. For example, reimbursement rates for a standard cleaning may be as low as $5 under certain HMO plans. This can mean that “standard care” doesn’t even cover its own cost, and the dentist is forced to earn their income from additional treatments.
Some insurance companies are more generous with the range of treatments for which they provide reimbursement. Others provide limited or no coverage beyond the most straightforward care, requiring dentists to rely on up-front payments from their patients in order to provide quality care.
Finally, depending on the insurance provider, the dentist may be paid quickly, slowly, or not at all. And in the continually evolving insurance industry, these payment timelines are not always consistent, let alone guaranteed.
Uncertain payment terms and timelines not only place stress on a dentist’s budget, they also require staff to spend hours on follow-up work. “Practices can spend hours trying to collect payments on basic procedures that should have been covered by an insurance carrier,” says Dr. Dino, “For example, a dentist provides a filling for a patient. First, the practice receptionist contacts the insurance carrier to pre-estimate the treatment. The patient is notified of their co-pay, and the dentist anticipates that they will receive reimbursement.”
“The procedure is completed and, a month later, the insurance company notifies the dentist that they will not receive payment. The dental office must then contact the insurance company, often being on hold for as long as 30-45 minutes in order to get an explanation of the denial. The dental office must then re-submit the claim, often waiting for up to another month. Sometimes, after all this work, the insurance company still denies a claim.”
Dr. Dino concludes, “This process is done to deter some offices from pursuing a claim, and thus not getting paid. In this model, the patients are then held liable for the cost of treatment.” Dr. Dino also advises, however, that new “membership models” help eliminate this back-and-forth, by eliminating the middle-man.
What can go wrong
What happens if you are a dentist who has a full patient count, but you have partnered with insurance providers whose standard reimbursements are barely profitable, or whose repayments are unreliable? You can solve this in three ways: Seeing more patients, recommending additional treatments, or promoting up-front payments.
Seeing more patients requires working more hours, spending less time with each patient, or both. This can lead to the “assembly line” feeling of many dental practices. And it can lead to dentists providing “impersonal” care – minimizing the time they spend with each patient, rather than building a relationship, thoroughly explaining care options, etc.
Recommending additional (higher-margin) treatments may be presented as providing conscientious care. However, it often means recommending treatments that are not medically necessary, but make providing care financially viable for the dentist.
Promoting up-front payments leads some dentists to eschew insurance completely, and running a strictly “direct-payment” practice. Other practices accept insurance, but recommend treatments that they know are not covered, thus requiring direct payment.
In the worst case, a dental practice will pursue all three strategies. They will accept low-quality insurance plans to get as many patients through the door, and will treat them as quickly as possible. Instead of providing tailored care, they will focus on “up-selling” patients on as many treatments as possible, creating higher profit margins. And they create a sense of urgency which, combined with the easy availability of payment plans, can generate large payments to the dentist, the cost of which patients must then bear for months or years, afterwards.
What can go right
Thankfully, it is equally possible to build a profitable dental practice without pursuing any of the above strategies. Dentists can build quality practices by:
- Limiting insurance partnerships to those providers known for quality coverage and reimbursement
- Focusing on patient-focused, rather than financially-focused, treatment recommendations
- Building a patient list primarily through referral, rather than primarily through insurance provider leads
Dentists who successfully pursue the above strategies are able to dedicate more time to each individual patient, building relationships and clearly explaining treatment options. They are also able to forego recommending profitable but unnecessary treatments, because their business model is financially viable through routine treatments and naturally occurring special cases. In the long run, this also provides for a more stable business model, as they face lower patient turnover (fewer dissatisfied patients leading the practice) and less “reputational risk” resulting from the same discontent.
Steps to be an informed patient
There are several simple things individuals can do to help them decide whether they are in a “quantity” or “quality” dental practice:
- Get a sense of the waiting room atmosphere. Do the staff appear rushed and brusque, or are they happy to greet you and answer questions?
- Observe “bedside manner” Do the dentist and hygienists take time to engage with you personally, or do you sense they’re “racing against the clock”?
- Understand treatment recommendations. If an additional treatment is recommended, does the dentist take time to fully explain their rationale?
Additionally, here are a few questions patients can ask their dentist to assess the practice’s approach to treatment, and business model:
- Are there alternative treatment options to a given recommended treatment?
- When should I have this procedure done?
- What are the consequences of not having this procedure done?
The above questions are only a guide, but should help gauge whether a dentist is taking the time to educate the patient on their condition, or if they are primarily trying to sell them a treatment.
The choices a dentist makes can go a long way to determining the level of care patients receive. And the choices patients make as consumers can heavily influence the care options available to them, and how much they pay for such treatments. By understanding the core dynamics of how dental practices succeed, patients can gain an intuitive sense of whether or not their dentist is taking a patient-focused approach to their care, or whether financial motives might be interfering with providing quality care.
DNA Dental Studio is a family-centered private dental practice, that focuses on building honest, long-term relationships with their patients, and in the community. They provide a full range of dental services, with an emphasis on family and cosmetic dentistry.