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Dentistry is a profession with many stakeholders and contributors. The industry includes clinicians, auxiliary staff, educators, researchers, politicians, dental suppliers, professional organizations, practices, clinics, hospitals, laboratories, manufacturers, dental societies, government agencies, and insurance companies. In 2018, over $134 billion was projected to be spent on dentistry in the United States.1 In the optimal scenario, the collective focus of all stakeholders should be on the patient. Unfortunately, when patients are asked to provide reviews of their experiences at healthcare facilities (dental practices, hospitals, universities, and dental clinics), they often indicate that their needs and wants remained partially or completely unaddressed.2 Ironically, a significant opportunity awaits the dental team through the practice of value-based dentistry (VBD), in which patient needs and desires in the context of cost of care are the priority.3,4
A variety of factors affect the success of a dental practice. In the authors' opinion, one of the most important factors is the recruitment of new patients willing to commit to, and undergo, newly proposed treatment. That does not mean that recall and ongoing patients deserve less attention-there should never be stratification of quality of care based on anticipated financial gain. However, the disparity in margin cannot be ignored; costs associated with providing dental care must be covered or a dental practice cannot survive. A basic aspect of business management is that one must find the right blend of circumstances to be successful.
Despite varying mechanisms to incentivize the relocation of dentists to rural areas across the United States, the vast majority of dentists practice in urban and suburban locations.5 Every major city and town seems have a dental office in every strip mall and on every street corner. How does a dentist successfully attract new patients when there are so many dentists from whom to choose? Why does a patient choose office X to call to make a consultation or examination appointment and not office Y or Z? What are the criteria that new patients choose to use when deciding whether to call one office or another for that first appointment? The answer to these questions lies in the concept of value creation. Value creation allows a patient to learn of the existence of the office and then determine that it has something to offer that he or she needs.
How Patients Find a Dental Practice
1. Location: Regarding location, it is obvious that a practice that is simply visible is easier to notice. However, one can increase the impact of visibility by establishing the practice in a high-traffic area. In essence, if many individuals are constantly seeing what appears to be a successful practice, they are more likely to want to inquire about it, especially when proximity is a factor of consideration.
2. Face-to-face word-of-mouth referral: Endorsement by friends, family, and colleagues carries significant weight. A personal recommendation of this kind is powerful and ideally the type of referral desired. Practices that sustain themselves on this type of value creation alone have high patient satisfaction. It takes time to build this type of practice, but once it is achieved, the benefits can be long-lasting.
3. Digital word of mouth: Advertisements come in many shapes and forms. They have infiltrated the world of social media, having daily access to billions of individuals worldwide. In dentistry, it has become almost standard for practices to have an online presence. This includes a functional, attractive website with search engine optimization and online review management. The online presence, in conjunction with what people are saying about the practice, can determine whether the practice will be successful or not and influence overall practice growth. Using social media effectively can be exceedingly helpful and is encouraged.
Imagine that one has managed these three paths of value creation well and that there is a steady number of new patients calling to make appointments for their first visit. Now, the challenge is to turn value creation into value capture. The practice has done the hard part in creating sufficient value in the minds of new patients that they have called the office and made an appointment. The office must convert a large proportion of these new patients into patients who seek treatment; the office must capture the value it created. In general, a practice is difficult to sustain financially on consultations and radiographs alone. As in medicine, the nature of revenue generation in dentistry is through treatment rather than consultation. Of course, ethical treatment precludes overtreatment, but given the way dentists are reimbursed, a certain ratio of treatment to consultation is necessary. Until that time when the emphasis on revenue generation changes, these are the circumstances to navigate.
Converting Value Creation to Value Capture
Value can be defined as the net ratio of quality achieved relative to cost endured.6
Value = Quality/Cost
The notion of value in dentistry can be viewed from the perspective of all aforementioned stakeholders. However, VBD focuses on the quality and cost measures from the perspective of patients. Dentists, in general, tend to be unsure of how to measure quality; they perceive quality as a nebulous term. This article attempts to remove doubt and offers a framework to use for assessing quality. When measuring cost, dentist colleagues tend to use financial cost as the dominant factor. This article discusses different contributors to cost, including financial cost from a patient's perspective.
Quality can be measured, not always easily, in three broad, patient-centered categories: outcomes, service, and safety.6
1. Outcomes. First is the outcome measure, which typically represents how well a patient's chief complaint is addressed in one or more of three main areas: appearance, pain, and eating/speaking.
Other factors with regard to quality that are also important to patients include the following, all of which may influence patients' decisions to proceed with dental care:
• Appearance/cosmetics/esthetic outcome
• Pain/discomfort resolution
• Masticatory performance outcome
• Speech/phonetics outcome
• Invasiveness of treatment (surgical versus nonsurgical)
• Need to sacrifice teeth/periodontal support/alveolar bone
• Time to complete treatment
• Number of appointments to complete treatment
• Financial cost of treatment
• Likelihood, frequency, and cost of routine maintenance
• Likelihood, frequency, and cost of potential complications
• Distance/time needed to travel to provider location
• Single care location or multiple care locations needed for treatment
• Other priorities for patient
• Wishes of family/friends
• Past positive dental experiences of patient or family/friends
• Past negative dental experiences of patient or family/friends
However, it has been found that patients' chief complaints tend to be in one or a combination of the three broad areas of appearance, pain, and eating/speaking. Having deconstructed quality into these simple categories, it becomes easier to discuss expectations, as well as assess one's ability to meet those expectations with patients. The final arbiter in success is the patient. If a dental provider believes a beautiful crown was made for a maxillary central incisor but the patient feels the crown looks terrible, then in a patient-centered practice, the provider has failed. Therefore, it is vital to understand that consultation is part of the value-creation experience. Understanding a patient's expectations to determine the likelihood of a mismatch between those expectations and the provider's expectations is crucial. Also important is acknowledging that sometimes, given a mismatch, no treatment is the best course of action.
2. Service. The second major category that contributes to quality, from the patient's perspective, is the service that the patient experienced. How well patients feel they were listened to, respected, cared for, and valued by every member of the dental practice team is important. Did the team learn and focus on the things that really mattered to the patient? Or did they not spend much time listening to the patient and instead decided for the patient a treatment option based on looking at a radiograph or a cursory clinical examination? There is only one opportunity to make a good first impression; patients are typical human beings in that they make quick judgments about factors such as trustworthiness, and these judgments may be difficult to change without major effort.
Giving oneself the perspective of the patient, one knows that a large marker the patient uses to assess the dentist's ability is how painless the anesthetic injection is. Most patients are often afraid of this procedure; if done well, it will lead to word-of-mouth referral. Making an injection painless is better attained if one takes time to use topical anesthetic for a minimum of 60 seconds and inject slowly.7 Yet some dentists rush through this procedure, perhaps unaware that patients may judge everything else that is about to happen based on how well this procedure goes.
Additional ways to improve the service experience include calling patients after an appointment to see how they are doing, remembering names of their family or recent activities they mentioned, and being transparent about the cost of treatment and payment options. These examples may seem mundane, but they are important to patients who are looking for markers of how much the practice cares about them. The elegance of the physical practice space also contributes to the overall patient service experience. A modern, sufficiently well-appointed and equipped practice generates confidence in patients. Given that much of dentistry is elective, showing patients that one cares about them goes a long way.
3. Safety. The third element of quality is safety. In medicine, safety and risk management are paramount because the likelihood of potential consequences may be higher and more severe than in general dentistry. Extracting a tooth due to iatrogenic causes is certainly undesirable, but the outcome is likely less severe than medical iatrogenic circumstances overall. Furthermore, consequences can be managed more easily than in medicine. However, patients must still feel safe and confident, especially when they take a heuristic approach to judge whether the dentist will keep them safe. An example is how a patient perceives the cleanliness and clutter of an office. An unkempt office may send a powerful negative message to a patient. Thus, something as simple as making sure the dental chair light cover is clean is important because the patient may be staring at it for a while. Discomfort during intraoral x-rays is another measure that is emotionally charged; patients may dread them. Taking time and being gentle makes a big difference and leads to the desired result of not just happy patients, but patients who will tell their family and friends about their experience.
Cost includes five broad, patient-centered categories.6
1. Financial cost is a category on which many patients focus because of the perception that dentistry is expensive, and perhaps too expensive for the quality results that the patient is hoping to receive. It is easy to measure. Transparency regarding financials-earning the patient's trust as a result-can offset a patient's angst with the actual numbers.
2. Biological cost is a category that does not receive sufficient attention. This factor, involving elements such as pain, swelling, bleeding, or sacrifice of hard (teeth/bone) or soft (gingiva/mucosa) tissues, matters greatly to patients and may be the sole determining factor in whether a patient chooses a surgical path over a nonsurgical path, even though the surgical path may yield a better-quality outcome. An example where this is relevant would be of a patient who declines implant therapy because of an unease felt about the surgery. This may lead that patient to accept life with complete dentures instead.8
3. Time/effort cost. Different treatment choices come with different time and effort commitments, whether it be total time for treatment, number of appointments, or how long it will be before an important milestone is achieved. Objectively, time can be measured easily. Subjectively, the cost of time is different for every patient.
4. Ongoing/maintenance costs. A conversation about ongoing and maintenance costs may force a conversation about prognosis to take place. How long may an amalgam restoration last? What type of problems may the patient have with veneers, and how easy or difficult will they be to fix? Whether it is the need to reline a denture, the possibility of screw loosening with an implant crown, or debonding of a restoration, the list is long. Discussing these possibilities with patients is important to educate them that nothing lasts forever.
5. Opportunity cost of treatment is often overlooked by dentists, yet patients will calculate whether it is the right time for dental treatment given the other priorities in their lives. The time, effort, and money involved in going through treatment could be spent elsewhere. It is not uncommon for patients to present for a consultation, have a great experience at a dental practice, and then "disappear," only to return months or years later ready to start. They were not initially ready to start because they had other things that took precedence; they are ready now.
Using the Value Equation
Value = Quality (Outcomes + Service + Safety)
Cost (Financial + Biological + Time/effort + Maintenance + Opportunity)
The value equation is a useful tool when discussing treatment options with patients.6 By breaking it down into the different constituents during a consultation, patients are better able to discern differences between the options that matter to them and make the decision that is best for them. Introducing the latest, best evidence and incorporating it into the quality and the cost elements of the equation, and then allowing patients to choose the path forward that best meets their needs based on the dentist's experience and their individual circumstances, offers the best opportunity to satisfy patients.
VBD promotes patient-centered care by balancing the latest scientific evidence with one's own experience as a clinician to prioritize individualized decision-making by patients based on their needs, preferences, and beliefs. Neither the latest evidence nor the dentist's experience, although they are important, should dictate the final decision for a patient. VBD puts the patient first and requires shared decision-making in which a conversation takes place between patient and clinician rather than merely an exchange of information.3,9
When patients are placed at the center of everything a practice does, the practice creates a cycle of satisfying patients. It starts with patients experiencing something worthwhile and later telling their family and friends about their experience. Then it falls on the dental team to create value with new referrals and then capture that value through patient-centered care that satisfies these new referrals. The new patients thus leave the office immensely content, and the cycle repeats itself. What results is happy patients and a practice that thrives in the present and in the future.
About the Authors
Sreenivas Koka, DDS, PhD, MBA
Koka Dental Clinic
Lecturer, Advanced Prosthodontics
UCLA School of Dentistry
Los Angeles, California
Clinical Professor, Advanced Prosthodontics
Loma Linda University
Loma Linda, California
Wayne D. Gonzales
4th-year dental student
UCLA School of Dentistry
Los Angeles, California
Sai Vishnu Pokala
4th-year undergraduate student
San Diego State University
San Diego, California
Marc Hayashi, DMD
Director of Undergraduate Clinical Education, Restorative Dentistry
UCLA School of Dentistry
Los Angeles, California
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