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Extensive material has been written and produced about how to improve practice performance. Topics often include understanding the role of the team, managing dental insurance companies, improving scheduling, and increasing case acceptance. The American Dental Association, for example, has a large library of practice resources available.1 One challenge for dentists when learning about these topics is that much of the material, whether gleaned from an article, post, and/or podcast, can be difficult to apply in a practical manner. These actions that a practice might take to improve performance can only be effective if there is a foundation of practice management in place. Unfortunately, many dental practices attempt to increase production without fully understanding necessary fundamental factors. In an era of staffing challenges, increased overhead due to inflation, and fairly flat reimbursements from dental insurance companies, it is crucial that dental practices understand how to increase production every year.
Challenges in Today's Economic Climate
Every business in every industry faces challenges, especially if that business wants to grow. To begin understanding how to increase practice production, dental practices need to evaluate the challenges they face today. Some of these challenges are as follows:
Lack of business training. Dentists learn little or nothing about running a practice while they are in school. However, dentists must become educated as to the best ways and methods to operate a practice or engage experts to handle this function. It is also important to understand that a practice cannot put a set of practice management systems (such as scheduling, hygiene productivity, case acceptance, customer service, etc.) in place one time and then forget about it. This would be analogous to assuming that one can go to the gym, get in top condition, and then never have to go there again. Just as the physical benefits of exercising at a gym will expire if one stops going, the benefits of management systems will run out (ie, plateau or decline) if the practice does not continue to utilize and improve these systems. In this current era of exciting new dentistry breakthroughs in materials, technologies, and techniques a practice cannot merely establish its systems once and then ignore them and expect to operate at maximum performance.
A staffing crisis. Practices are experiencing challenges in hiring team members, operating short staffed, and settling for reduced training levels for new team members.2 The simplest and optimal way to address and improve team training is to implement (with documentation) proven and tested business systems for all aspects of the practice. The team must then be trained in these systems, be exhorted to consistently use the systems, and measure results, all as part of a positive approach to team building and enhancing practice performance. Usually, most team members desire to do an excellent job and excel, and they look to the doctor(s) and office manager(s) for their cues. In the author's observation, the team will gradually begin to take on the attitude and approach of the leadership. That is, the team will develop very much like the doctors and office managers in regard to daily actions and attitudes. Therefore, doctors and office managers must examine themselves to determine if they are acting and behaving as they would like the staff to develop and act.
Stagnant dental insurance reimbursements. Dental insurance reimbursements are beyond the control of dentists or dental practices. For the most part, dental insurance companies currently are not increasing reimbursements, and some (according to many practices) have decreased them in recent years. This is a trend that is expected to continue with occasional slight increases. In general, dental insurance carriers will continue to carefully monitor reimbursements and minimize the level of reimbursement where feasible and possible.
This creates a different type of practice management challenge for dental practices. In most cases strategies can be employed to address this challenge that can be highly successful and help increase practice production in order to offset limits in insurance reimbursements. Some of these strategies are listed in Table 1.
Competition. Although there has always been competition in dentistry, today's level of competition is unprecedented. An array of different service delivery options now ranges from solo practices to dental service organizations (DSOs). There are also different levels of fees and marketing enticements to attract patients to join a practice. Some practices even emphasize their unique services that not all practices offer, such as sleep dentistry, temporomandibular disorder (TMD) treatment, botulinum toxin (botox) treatment, and clear aligner therapy, just to name a few. This is the current state of competition in dentistry, and it will likely increase over time. While this in no way implies that a practice or group of practices cannot attain success, it reinforces the importance of practices implementing management systems that can help facilitate success and heighten production levels.
Identifying Opportunities
The author's firm, with more than 40 years of experience in dental management consulting, believes that most dentists will lose out on potentially many millions of dollars over the course of a career. This is due to a multitude of missed opportunities, such as failing to reduce no-shows, increase case acceptance, improve hygiene production, and reactivate overdue patients. The practice needs to identify any and all opportunities that are significant for increasing production and implement systems to maximize these opportunities. Naturally, the earlier a practice acts to implement excellent management systems, the faster it will achieve results.
Increasing practice production by a significant amount does not happen overnight. A process needs to be followed involving a number of strategies outlined below. Several of these recommended strategies might take anywhere from 1 to 3 years to fully implement, but they have the potential to deliver substantial production increases. Over the course of a career, these increases can be a major "game changer" in regard to not only practice production, but practice profitability and doctor income. In an era where dentists are retiring later than in the past and carrying student loan debt for longer, the cycle for dentists to become financially independent is longer.3 Therefore, increasing practice production leading to higher doctor income can be a great benefit to any dentist.
Production Strategies
Strategy No. 1: Continually Add to the Patient Base
Not surprisingly, new patients contribute to practice production. However, what is not as obvious and often not measured is the actual size of the patient base. Practices should track the number of active patients each year, with a goal of increasing this number. Often, the number of patients that are either overdue or no longer active as a patient of the practice goes unrecognized. In an era where patients are more willing to change practices based on the availability of other service delivery models such as DSOs or changes in their dental insurance, maintaining and growing a patient base takes more focus than in the past. Inflation periods or a bad economy are other factors that also influence patients.
One way to ensure a growing patient base is to designate time every day to contacting patients who are overdue. Many of these patients have basic hygiene needs in addition to other dental needs that perhaps have gone undiagnosed because of their being absent from the practice. Furthermore, patients who are less active or inactive in the practice are often less likely to refer others. A large patient base will help a practice withstand challenging times even when a percentage of patients decide to either postpone dentistry or not accept treatment. Overall, growing a patient base is a significant benefit to almost any dental practice and can add millions of dollars of revenue over the course of a dentist's career.
Strategy No. 2: Increase Case Acceptance
Many dentists believe they are excellent at case presentation, and, in fact, many are very capable of effectively presenting relatively small cases, such as single-tooth restorations. Presenting complex cases, however, is more challenging, and, in the author's observation, dentists are generally not trained in sales methodologies. Dentists need to take time to understand that case presentation is a systematic process and when steps are properly followed, the likelihood of case acceptance is much higher. Examples of actions that can help increase case acceptance include developing a relationship with the patient, demonstrating care and excellence in customer service, focusing mainly on the benefits of the treatment when presenting the case, and providing testimonies from other patients with similar diagnoses who had successful treatment.
Dentists cannot simply extemporize when it comes to case presentation. Case presentation must be approached in a systematic way, where the practitioner understands the motivational and influential factors that help patients make positive decisions. A practice should measure the level of cases that are unaccepted or incomplete, and then try to understand why the treatments were rejected. An additional recommendation is to make a follow-up call to all patients 1 week after a case presentation to encourage them to schedule. Furthermore, any patients who have not completed treatment should be contacted regularly until they schedule their appointment. Again, in the author's observation, consistently reaching out to patients can have a significant impact on their decision to schedule treatment.
Strategy No. 3: Increase the Number of New Patients
Because they often have dental needs that may have gone unattended for some time, new patients are an excellent source of production. In a review of 300 practices, the author's firm determined that new patients have a higher financial value to practices in their first 12 months than current active patients, meaning that new patients yield higher overall production.
Practices often invest in marketing activity to increase the number of new patients; however, the investment may be wasted if two key factors are not in place. First, the new patient phone call is critical. When a new patient calls, well thought-out, specific scripting needs to be in place to create a sense of value, caring, and trust. These calls should be more than simply logistical and administrative in nature with the front desk person only focusing on getting the patient scheduled and recording their basic information. Guidelines for scripting for a new patient phone call are provided in Table 2. If there is a lack of preparedness for a new patient call, many of these patients might either not schedule or end up canceling or not showing up for their new patient appointment. Again, this is something that practices should measure: the percentage of new patient phone calls that do not result in an actual appointment.
The second factor practices must consider to make their marketing efforts pay off has to do with blocking out new patient appointments. The practice needs to have enough new patient appointments blocked out to contribute to its daily and monthly goals. Moreover, new patients should be scheduled as soon as possible ("strike while the iron is hot"). Pushing out their appointment for a number of weeks should be avoided, because a lengthy waiting period only allows the new patient more time to decide not to keep the appointment.
Practices should have a specific, mathematically defined number of new patient appointments each month to contribute to the overall production goals of the office. For example, the author's firm recommends that 40% of doctor production be generated from new patients. If the annual production goal is $1,000,000, then $400,000 should come from new patients. Using the practice's average production per new patient statistic, the scheduling coordinator should ensure that sufficient appointments are blocked for the purpose of bringing new patients into the practice within 7 days of initial contact in order to achieve the $400,000 goal.
Strategy No. 4: Train and Retrain Dental Hygienists
Dental hygienists are perhaps the most underutilized professionals in the dental industry. Typically, they are highly trained to perform many different procedures, including periodontal scaling and root planing treatments, yet in most offices they are used strictly for performing dental cleanings. Dental hygienists should be viewed as professionals in the same manner physicians look at nurses. They need to be given guidance and independence to work with patients at levels beyond the provision of hygiene and be permitted to identify other potential treatments, make recommendations, inform the doctor, and have doctor support. Dental hygiene can often increase in production quickly if factors such as the following are put in place:
Annual periodontal diagnosis. Having hygienists perform periodontal diagnoses will lead to the identification of many periodontal cases that are in the best interest of patients and the practice.
X-rays and fluoride. Practices should be aware of patients who are behind on services such as x-rays and fluoride treatment. The practice must make the time to get patients up to date on these services.
Sealants. Sealants are often underused for children and even elderly patients who have increasing levels of decay. Sealants should be a priority for these two patient groups.
Additional services. Hygienists should become adept at motivating patients to consider esthetic, implant, or other treatment, depending on services offered by the practice. Suggesting additional services that will benefit the patient should be a talking point for hygienists during all dental visits.
Training. Hygienists need to be trained thoroughly in dental diagnosis to identify necessary treatment for patients and then be able to motivate patients to have treatment provided by the dentist.
Strategy No. 5: Decrease No-Shows and Last-Minute Cancellations
A dental practice needs to track the percentage of no-shows and last-minute cancellations that occur in the practice schedule. Failing to do so is a mistake. No-shows can cost a practice millions of dollars because lost chairtime can never be recouped.
Practitioners can calculate their lost production by reviewing the past 12 months of last-minute cancellations and outright no-shows and multiplying that figure by the number of years they have been working. The total will likely be quite surprising. The reality is that in most practices no-shows often go unaddressed and there is no system in place to track and manage them. Many practices may "give a pass" to a patient who cancels at the last minute; however, even though the patient called, the time cannot be filled in, making a last-minute cancellation very similar to being a no-show.
To address this issue, practices can "train" patients to not miss appointments. First, the practice must create a sense of value for dentistry and for that particular dental practice. In the author's experience in reviewing practice data, it is clear that the highest no-show rate is in the hygiene area, and this is because many patients simply equate a hygiene appointment with a cleaning. In their view, the appointment may not seem important and can be missed and rescheduled without penalty. Thus, this reinforces the need for creating value in the appointment. Second, the practice needs to create a system to decrease no-shows and last-minute cancellations. This involves the use of scripted phone calls. Patients who cancel with little notice or who fail to show need to be called and politely told that there is a fee for a no-show. While the practice can choose not to actually charge the patient, which could create conflict and prompt the patient to leave the practice, it lets the patient know that any future no-shows may incur a charge. This typically should eliminate no-shows for most patients.
Conclusion
Increasing practice production is not a pipe dream, and many practices are able to achieve it once they understand the importance of production in a highly competitive and challenging profession. All businesses have challenges and competition, and in dentistry the solution to meeting and overcoming these challenges is to implement strategies and systems to increase practice production. By addressing just a few key areas as noted above, practices can move toward increasing production by significant amounts, which also leads to greater practice profitability and doctor income. This, in turn, can reduce the number of years it takes for a dentist to reach financial independence while simultaneously creating high levels of efficiency leading to smoother operations and more enjoyable workdays for both the doctor and the team.
Every dental practice should strive to seek ways to increase practice production. Some of the strategies outlined in this article can have a multi-million-dollar effect on a practice, while others will have lesser, although still impactful, effects. When combined, these strategies will help increase production and reap major benefits for both the dentist and the practice.
About the Author
Roger P. Levin, DDS
Chief Executive Officer and Founder, Levin Group, Inc. a dental management consulting firm that has worked with more than 30,000 dental practices
Queries to the author regarding this course may be submitted to authorqueries@conexiant.com.
References
1. American Dental Association, ADA Store. https://engage.ada.org/pages/storehome. Accessed November 4, 2024.
2. ADA Health Policy Institute in collaboration with American Dental Assistants Association, American Dental Hygienists' Association, Dental Assisting National Board, and IgniteDA. Dental workforce shortages: data to navigate today's labor market. October 2022. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/dental_workforce_shortages_labor_market.pdf. Accessed November 4, 2024.
3. American Dental Association, ADA Health Policy Institute. U.S. dentist retirement and career span trends. ADA website. https://www.ada.org/resources/research/health-policy-institute/dentist-workforce/dentist-retirement-trends. Accessed November 4, 2024.
