Page 1

CZZh Dr. Jack Devereux & Dr. Phuong Nguyen Q1 2017

BUSINESS PRACTICE & DEVELOPMENT A CLEAR PATH TO EFFECTIVE BUSINESS PLANNING – BY SARAH SHARFSTEIN, MBA

MARKETING/ SOCIAL MEDIA

YOUNG DOCS

HELP FOR YELP, PROTECT YOUR REPUTATION

THIS AIN’T THE TIME FOR YOUR

-BY DR. DOVI PRERO & DR. SHELDON SALINS

-BY DR. MARC ACKERMAN & DR. BEN BURRIS

DADDY’S CONSULTANT!


orthodontists are people too. get real online and get the best patients.

• practice listings • websites Call us at (877) 436-0134 for more information. gobanyan.com

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inside this

edition...

COVER STORY

CZZh

DN Orthodontics BUSINESS PRACTICE & DEVELOPMENT

12 Behavioral Economics Meets Orthodontics BY CLAUDIA EISENHUTH

21 The Plastic Employee BY DR. JONATHAN NICOZISIS

Page

42

MARKETING/ SOCIAL MEDIA

26 Help for Yelp, Protect Your Reputation BY DR. DOVI PRERO & DR. SHELDON SALINS

28

40

A Clear Path to Effective Business Planning

BY ANGELA WEBER

Are Orthodontists a Commodity?

Increasing Access to Care: SmileDirectClub’s Growing Role in Outpatient Orthodontics

YOUNG DOCS

This Ain’t the Time for Your Daddy’s Consultant!

42

BY DR. MARC ACKERMAN & DR. BEN BURRIS

Meet DN Orthodontics Bands to Brackets & Analog to Digital BY DR. BEN BURRIS

63 Three Pillars of the Modern Practice, Part 2: Leverage

The Yin Yang Attachment: The Clear Path to Molar Zen BY DR. JONATHAN NICOZISIS

ORTHOPUNDIT.COM

Doctor, Please Stop Assuming BY DR. NONA NAGHAVI

10

BY DR. ROBERT SIMS

56

50

68

BY SARAH SHARFSTEIN, MBA

38

CLINICAL CORNER

OFFICE LOGISTICS

33 Is it Time to Leave the Stone Age?

H.R. INSIGHT

BY DR. CHRISTIAN GROTH

17 Conducting a Candidate Site Visit; What You Need to Know BY SHANNON PATTERSON

RESOURCES

72

Resources

BY DR. JAMIE REYNOLDS

The ideas, views and opinions in each article are the opinion of the named author. They do not necessarily reflect the views of The Progressive Orthodontist, its publisher, or editors. The Progressive Orthodontist® (“Publication”) DOES NOT provide any legal or accounting advice and the individuals reading this Publication should consult with their own lawyer for legal advice and accountant for accounting advice. The Publication is a general service that provides general information and may contain information of a legal or accounting nature. There is no guarantee or warranty regarding the information contained in the Publication and we are not responsible for any loss, injury, claim, liability, or damage (“damages”) related to your use of the information contained in the Publication or from errors or omissions in the content of the Publication. While we have worked to make our Publication and all the features in the Publication as helpful as possible, the Publication does not endorse any content provided by any feature, nor does it assume any responsibility for the interpretation or application of any information originating from such content. In addition, The Progressive Orthodontist does not endorse any content contained in any advertising on the Publication, nor does it assume any responsibility for the quality or integrity of such work. Content is property of The Progressive Orthodontist and may not be copied or otherwise duplicated without prior written consent from The Progressive Orthodontist. All content contributed to The Progressive Orthodontist magazine becomes the property of SmileMedia. The publisher assumes no responsibility for return of unsolicited manuscripts, art, photos or other content.

Q1 • 2017 | TheProOrtho.com 1


EDITOR’S NOTE

EXECUTIVE EDITOR Dr. Ben Burris

CLINICAL EDITOR Dr. Derek Bock

PUBLISHER Carrie Halley

It’s a new year and we are living in a brave, new world. In that spirit we have an incredible issue of The Progressive Orthodontist Magazine for you. Everything is changing technology, business models, marketing, philosophy and practice - and we have articles exploring the latest iterations of each in this issue. Being closed minded and confident in what “you’ve always done” makes us feel good but it’s not a good idea if you want to thrive in the new dental landscape. I witnessed the immense change in our industry up close and personal at The MKS Forum and The Invisalign Summit. Anyone who attended one or both of these meetings knows what I mean. It’s amazing to watch relationships and connections bloom at these meetings and in the online forums. The interconnectivity of orthodontists is going to play a major role in shaping the future of our specialty. If you’re not plugged in I strongly suggest you think about joining us.

ADVISORY BOARD Dr. Jason Battle Dr. Derek Bock Bridget Burris Dr. Courtney Dunn Dr. Jennifer Eisenhuth Dr. Kyle Fagala Dr. Jose Luis Garcia Dr. Anil Idiculla Dr. Alfred Jackson Dr. Aly Kanani Dr. Kliff Kapus Dr. John McManaman Dr. Nona Naghavi Sarah Sharfstein Dr. Jason Tam Angela Weber

GRAPHIC DESIGNER Megan Clark

Happy New Year! I wish the best for you, your family, your business and your patients. Thanks for taking this journey with ProOrtho! -Ben

Advertise with us Susie Snow 994-202-1010 The Progressive Orthodontist magazine and study group are your educational resources for new trends, progressive insights and best practices for building a successful orthodontic practice in 2016 and beyond.

CHECK US OUT ONLINE WWW.THEPROORTHO.COM 2

It’s just BUSINESS


Life is all about choices. Benco Dental offers a world of choices and a guide to help you navigate them. THE BENCO DIFFERENCE: We deliver a painless and innovative customer experience that improves the business engines, life balance, and patient care of dental professionals. We leverage leading-edge technologies, expert Success Partners, and our caring family culture. We choose listening over telling, a broad array of products and services over restrictive exclusives, and an insightful solution over an easy sale. • We earn and cherish our sterling reputation every day. • We assume positive intent, always. • We empower great people to do great work. • We give back to the communities and families we serve. • We begin each initiative by asking, “What does the customer want?” • We improve each process by asking “Why?” again and again. • And... we smile!


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DR. JOSE LUIS GARCIA

DR. JOHN MCMANAMAN

DR. ANIL IDICULLA

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SARAH SHARFSTEIN

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Q3 • 2016 | TheProOrtho.com 5


CONTRIBUTORS DR. BEN BURRIS RIS Article on page 10, 56 Contrarian, philanthropist, rabble-rouser, thought leader, business man, loud mouth, prime mover and visionary. These are but a few of the terms used to describe Ben Burris. No matter which label you choose or what personal opinions you hold, none can deny that Dr. Burris continues to change the conversation in dentistry - especially in orthodontics. Dr. Burris graduated from The Citadel, in Charleston, SC, with a BS in biology prior to receiving his DDS from the University of Tennessee - Health Science Center’s College of Dentistry in 2001 where he then completed his orthodontic residency and received his MDS in 2004. Burris is owner of one of the largest practices in North America, creator of Smile for a Lifetime Foundation, co-owner of The Progressive Orthodontist Magazine and Study Group and key opinion leader to some of the industry’s heavy hitters. Ben can be reached at bgbdds@yahoo.com.

DR. PHUONG NGUYEN Article on page 42 Dr. Phuong Nguyen grew up in the New Orleans, LA area. After graduating summa cum laude at Xavier University, he went on to LSU School of dentistry where he graduated near the top of his class in 2000. Five years later, Dr. Nguyen continued his education and earned his Master’s in Business Administration at the University of New Orleans. Dr. Nguyen has been teaching orthodontics at LSU School of Dentistry since 2002. He has lectured extensively and published numerous articles in peerreviewed orthodontic journals. In both 2007 and 2008, Dr. Nguyen was recognized as one of the recipients of “America’s Top Dentists” award.

6

DR. JACK DEVEREUX Article on page 42 Dr. Jack Devereux grew up in the New Orleans, LA area and attended Louisiana State University from 1975 to 1978. He graduated first in his class at LSU School of Dentistry in 1982 and then went on to earn his Master of Science in Orthodontics at the University of North Carolina at Chapel Hill in 1985. Dr. Devereux has been in the practice of orthodontics in the New Orleans and Slidell, LA area since 1985. Dr. Devereux is a member of the local, state and national Dental and Orthodontic Associations, he has served as a president of the Louisiana Association of Orthodontists, and has also served on the Board of Directors for OrthoSynetics.

SHANNON PATTERSON Article on page 17 Shannon Patterson, CPR, CMSR is the Director of Practice Opportunities and an Orthodontic Placement Specialist at Bentson Clark & Copple. She is a recruitment leader in the orthodontic industry specializing in placement and retention by engaging a proactive recruitment strategy helping to place candidates where they will be a successful fit not only for the practice opportunity but also the community. She is also a Kolbe Certified™ Consultant and expert in the Kolbe suite of assessments for selection of the ideal candidate match specializing in strength based relationships for both doctors. She believes great clients deserve great candidates and great candidates deserve great opportunities.

It’s just BUSINESS

DR. JAMIE REYNOLDS O S Article on page 63 Dr. Reynolds attended d the University of Michigan for both his undergraduate and dental studies. While at Michigan he was a member of the volleyball team, earning both team captain and All-Big Ten honors. Dr. Reynolds attended the University of Detroit-Mercy earning a master’s degree in orthodontics. He lectures extensively on orthodontic technology and practice management and is also a co-founder of OrthoFi. In his spare time, he has a passion to travel, spend time with his family, and learn new things. Also, as a beach bum at heart, Dr. Reynolds can be found in the summertime near a beach volleyball court covered head to toe in sand.

DR. ROBERT SIMS Article on page 38 Dr. Sims grew up in the small Kentucky town of Flemingsburg. He moved to Lexington in 1978 to begin his higher education at the University of Kentucky, where he earned his bachelor’s degree in biology, master’s in microbiology, Doctorate of Dental Medicine, orthodontics certificate, and Master of Science in Dentistry (MSD). While in dental school, Dr. Sims received various research and clinical awards, including the American Association for Dental Research Award, the American Association of Orthodontists Award, the Quintessence Award for Research Achievement, and the Henry M. Thornton Fellowship Award from the Student Clinicians of the American Dental Association. Dr. Sims has also published articles and abstracts in national and international dental journals. Dr. Sims has been certified by the American Board of Orthodontics and is now a Diplomate of the American Board of Orthodontists.


DR. MARC ACKERMAN Article on page 10

DR. SHELDON SALINS Article on page 26 Dr Salins live in San Francisco Bay He did his Ortho at UCLA Some thought he was mental Because he went to Harvard dental But in the end - he turned out ok He does what most Ortho do Active in dental clubs, many not few Best are time with his kids, they’re great Bike riding With the boy named n8 And playing dolls with the girl, called Clo

ANGELA WEBER Article on page 40 Angela Weber is the Chief Marketing Officer for OrthoSynetics a company which specializes in business services for the orthodontic and dental industry. She leads a team of marketing professionals dedicated to developing and implementing cutting-edge strategies and solutions for their members. Angela has over 15 years of experience in the advertising industry with a vast knowledge of current and past trends, philosophies and strategies for marketing within the healthcare industry. Angela has a proven track record of driving new patient volume through innovate marketing practices. Angela holds a B.A. in Mass Communications from Louisiana State University and an M.B.A. from the University of New Orleans.

DR. DOVI PRERO O Article on page 26

Dr. Ackerman specializes zes in the orthodontic treatment of children with dentofacial deformity, intellectual and physical disabilities and sleep disordered breathing. He received his DMD from the University of Pennsylvania School of Dental medicine in 1998 and his certificate in Orthodontics from the University of Rochester-Eastman Dental Center in 2000. Dr. Ackerman later completed his MBA in Executive Leadership at Jacksonville University Davis College of Business in 2009. Dr. Ackerman is the Director of Orthodontics at Boston Children’s Hospital and teaches residents in both pediatric dentistry and orthodontics for Harvard School of Dental Medicine.

DR. JONATHAN NICOZISIS Article on page 21, 50 Dr. Nicozisis is a Faculty member of Invisalign® National Speaker’s Bureau and Clinical Research Network and has given over 400 lectures on Invisalig. Dr. Nicozisis is also the founding orthodontist and a scientific advisory board member of BAS Medical/Corthera a development stage company founded in 2003 with a mission to develop and market a novel technology to accelerate and improve the stability of orthodontic treatments. Dr. Nicozisis’ master’s research is the basis for BAS Medical innovative research. In February 2010, Corthera was acquired by Novartis. Dr. Nicozisis has been awarded membership to the Edward H. Angle Society of Orthodontists. He has co-authored a text book chapter on Invisalign with Align’s director of R+D. Since 2010, he is an SAB member of Propel Orthodontics.

Dr. Dovi Prero is an orthodontist in Beverly Hills, CA. He completed his dental degree at UCLA , Certificate in Orthodontics from USC, and a Master’s in Education from Loyola University Chicago. He is a Diplomate of the American Board of Orthodontics. His practice focuses on 1000% customer satisfaction and enjoys teaching colleagues about implementation of technology and authentic social media engagement. He can be reached at info@DrPrero.com

DR. CHRISTIAN GROTH Article on page 33 Christian Groth was born, raised, and practices outside of Detroit, Michigan. He completed his dental and orthodontic training at the University of Michigan and now is a partner with TDR Orthodontics. In 2015, Christian and his partners opened Motor City Lab Works, a digital orthodontic lab specializing in 3D printing. He has a passion for utilizing technology in order to improve the patient and staff experience. When not in practice, Christian enjoys spending time with his wife and two young children, running, and cheering on the University of Michigan.

DR. NONA NAGHAVI Article on page 68 Dr. Naghavi graduated from University of Toronto school of Dentistry in 2004 and completed her Orthodontic Specialty training at Jacksonville University in 2011. She lives and practices in South Florida.

Q1 • 2017 | TheProOrtho.com 7


CONTRIBUTORS SARAH SHARFSTEIN Article on page 28 Sarah Sharfstein is the Director, Marketing North American Ortho for Align Technology, Inc., the makers of Invisalign. Sarah has been with Align working in the Orthodontic field for over 9 years and has been in healthcare for almost 12. Within the field of Orthodontia, Sarah focuses on leadership, strategy, operational excellence and marketing. She brings a wealth of knowledge to each individual practice and Orthodontic Study Group she works with. Sarah is passionate about driving doctors and their teams to recognize top line revenue growth while increasing efficiency and profitability through the integration of Invisalign. When working with an individual practice, she takes a holistic approach to the business and in turn provides practice management solutions to drive its overall growth. Sarah earned her Bachelor’s degree from the University of California at Davis, and has a Master of Business Administration degree from Santa Clara University, with an emphasis in Product Management and Marketing.

CLAUDIA EISENHUTH HU Article on page 12 Claudia is studying economics and mathematics at the College of Saint Benedict and will graduate in 2017. She was selected to be an entrepreneur scholar and is applying to graduate programs this summer. Claudia writes with the intent of bringing behavioral economics and neuroscience into the applied realm of clinics, where these principles can be utilized.

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YOUNG DOCS

THIS AIN’T THE TIME FOR YOUR DADDY’S CONSULTANT! By Dr. Marc Ackerman & Dr. Ben Burris Bob Dylan once sang “the times they are a changin’.” Learn it. Live it. Love it. Embracing change is the only way to survive in orthodontics, but if you play your cards right and use your head, you can do a lot better than mere survival. We can’t always predict the future but we sure as hell can learn from the mistakes of our past. Despite what you’ve been told, there has never been a “Golden Age of

Orthodontics.” Those who pine for “the good old days” are merely self-identifying losers who can’t cut the mustard. The modern dental landscape is what it is and TODAY is what we have. Adapt and prosper. If we’ve heard it once, we have heard Paul Zuelke say dozens of times that, “nothing has changed in orthodontics in the past 30 years.” These statements (and

most of the surrounding) are so ludicrous that we have just ignored them in the past. However, given Paul’s recent talkativeness we thought it would be interesting to put his trademark claim to the test and take a look back at orthodontics in 1989, the year “Cash or Credit” was published to compare how different things are today. Take a look at the table below for just a few examples:

1989

10

2016

Wearing Gloves

Optional

Required

Practice Type

Solo/One Office

Group/Satellites

Treatment Fee Approach

Orthodontist Centered

Consumer focused

Financing

Cash

All modes of payment

Down Payment

25%

Low Down Payment

Billing

At Visit/Mailed Statements

E-Bill/ACH

Treatment Time

Longer

Shorter

Capacity per orthodontist

Lesser

Greater

Referrals

Dentist

Patient/DTC

Appointment interval

Shorter

Longer

Greater percentage of cases treated by

Extraction

Non-extraction

Esthetic Appliance

Clear plastic brackets

Invisalign

It’s just BUSINESS


YOUNG DOCS

Based just on this cursory survey, we think it idiotic to claim that nothing has changed in orthodontics since 1989! We know that most orthodontists and residents can reason this out for themselves. We wanted to take this golden opportunity to show in black and white that you MUST listen to what “experts” are telling you with a skeptical ear, especially when they don’t even have an orthodontic degree and have never practiced orthodontics.

–––––––––––––––––– With some effort and thought you can separate the wheat from the chaff and reap the benefits that interaction with your friends, peers, colleagues and even these alleged experts have to offer. When you do that, we all win as individuals and as a group!

–––––––––––––––––– Especially when they start their pitch with, “I’ve been doing this for 20, 30, 40 years…”! Question everything (we do, including our own beliefs!). Use your heads. You are obviously smart and successful to have done what you have and to be where you are, so trust yourself! We hope you are reading this piece and all of our others with a skeptical eye as well. We don’t want you to listen to us or take our words for it; we only hope to motivate you to ask questions and figure things out for yourselves since there is no one right way of doing anything as far as we can tell. With some effort and thought, you can

separate the wheat from the chaff and reap the benefits that interaction with your friends, peers, colleagues and even these alleged experts have to offer. When you do that, we all win as individuals and as a group! The new, connected orthodontic community is unprecedented and incredibly valuable, but we still must think rather than swallowing the information we are given as truth. The good news is that if there is a new technology developed, if there is a threat to the specialty or if one company sues another company and in the process threatens to screw colleagues, you’ll know about it on Facebook, OrthoPundit or Twitter within an hour of the news breaking! This is much quicker than getting our news at 6 O’clock, from a printed newsletter, from the AJODO or even from the AAO E-Bulletin.

–––––––––––––––––– Maybe we should consider the creation of The Internet a mildly important change that’s occurred during the last 30 years? ––––––––––––––––––

If you’re stuck with a difficult case, a treatment planning dilemma, a practice management problem or even an upset momma you can turn to an online study club where your peers help you out within minutes – much faster than the wine and dine country club event every other month. Oh, wait, doesn’t that alone mean that the entire fabric of how orthodontists communicate and run our businesses is different than it was 30 years ago? Maybe we should consider the creation of The Internet a mildly important change that’s occurred during the last 30 years? You’ll have to decide for yourself!

Q1 • 2017 | TheProOrtho.com 11


BUSINESS & PRACTICE DEVELOPMENT

Behavioral Economics Meets Orthodontics By Claudia Eisenhuth In today’s global society, industry leaders are focusing their attention on the enormous pressures of an increasingly competitive market: whether it be automobiles, clothing, electronics, agriculture, or even orthodontics. Orthodontic clinics in particular are currently facing a stampede of competition. In more recent years, there is a speculated 40% increase in the amount of primary care dentists providing orthodontic treatment, and there are no signs of this number slowing down. Now more than ever, we see increased opportunities for consumers to choose from a multitude of orthodontic treatment providers: board certified orthodontists, pediatric dentists, Primary Care Dentists (PCDs), online services, invisalign centers, or even mail-ordered aligners. With this large of a supply shift in orthodontic service providers, pricing has become an ongoing concern with many orthodontists. When business owners are threatened by increased competition, their typical knee-jerk reaction is to match or lower fees in order to maintain market share. Do today’s orthodontists, with the increase in competition, really need to lower their fees to maintain current levels of profitability, market share, and success? From a purely quantitative economics perspective, yes. Anytime there is a supply increase, supply will shift rightward and the price will fall (shown in the following graph). In general, economists observe this phenomenon on a national basis for many products. Does that mean that your practice has to lower fees? Not necessarily…

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The average price of braces varies across regions: geography will be impacted by the quantity of orthodontists, the demand for braces, fixed costs (e.g. rent), and other variables. The price of braces typically has less to do with material costs and more to do with the relative supply. Relatively lower prices will be found in highly competitive regions with a large supply of orthodontists, pediatric dentists, PCDs, and other competitors. The material costs are generally fixed, but other costs may not be similar among regions due to the variability of rent, labor, and other factors. From an economics perspective, running a successful orthodontic clinic requires maximizing total profit. Given the fact that each orthodontic clinic has varying productivity, each office should calculate their own profit maximization output. Increasing output does not always lead to an increase in profit, but pricing strategies can be more influential in a clinic’s profitability. The good news: orthodontists do not need to lower their fees when they are threatened with more suppliers. If competition increases, how can price

It’s just BUSINESS

variation still exist in the market? Consider behavioral economics, which is the study of how perceptual value is placed above and beyond the product or service offered. Why is it that some orthodontists have higher fees, seemingly untouched by increased competition? Product differentiation is present in even the most apparent goods that appear homogenous, like water or alcohol. For example, certain distilleries are able to charge irrationally high prices for a bottle of vodka. However every bottle of unflavored vodka is comprised of the same primary ingredient: pure ethyl alcohol. That being said, why is there so much price variation between vodka bottles? Despite the apparent homogenous ingredient involved, a generic brand of vodka will charge $8 for a bottle, while a high end bottle charges over $3 million. Two vodka products could have the same marginal costs and ethyl alcohol content, but companies will charge completely different prices with the use of branding and packaging (Conlon and Rao 9). The psychological effects of packaging have been measured in various studies: the visual cues of alcohol affect the interpretability of consumption (Louw 1). Smirnoff utilizes product differentiation on the shelves of liquor store: highlighting its country of origin, exotic name, marketing techniques, and a dark red label that associates their drink with Russia. Imported super premium brands took over the American vodka market by emphasizing their production and heritage differences (Grigorian 8). Therefore, vodka is terrific example of a seemingly uniform good whose


BUSINESS & PRACTICE DEVELOPMENT consumption is heavily influenced by the country of origin effect to gain consumer recognition in a global market. At this point you may be wondering, what does vodka have to do with orthodontics? Everything. If a globally competitive vodka company can convince consumers to pay double, triple, or fivehundred-thousand times the price of their competitors, an orthodontist can surely find ways to avoid lowering their prices, while maintaining market share in a thrivingly competitive industry. There are several concepts that support particular techniques to avoid being crippled by increased competition. The offices that have discovered these principles have successfully maintained higher fees without losing their market share. Below are a few techniques used by pioneers in every industry: EMOTION: The complexity behind the seemingly irrational decisions that consumers make in regards to paying more for one product over another comes down to two distinctions: a want and a need. The needs of human consumption include water, food, shelter, and air. The wants of human consumption include just about everything else, regardless of how much we would like to deny it: iphones, jewelry, cars, and countless other luxuries that we can afford by living in such a prosperous country. However, the relative prosperity of our nation allows us to be fooled into disguising luxuries as needs. The American government is even using taxpayer dollars to pay the phone bills of low income households, because personal electronics have become a need in the eyes of the government (Forbes 2010). Companies invest countless dollars to convince consumers that their product is a need, in hopes of altering buying behavior. From a behavioral economics perspective, emotion drives the minds of consumers seeking fulfillment. Two competing watch companies, Timex and Rolex, provide a wonderful example of attracting logically and emotionally driven purchases. The functionality of a watch is basically the

same: both are exquisite timekeepers. Why would a rational consumer pay $10,000 more for a watch? This consumer is probably not viewing timepieces as necessary commodities. A logic oriented consumer will seek a watch for the purpose of keeping time, but the emotionally compromised consumer will seek watches for reasons beyond functionality. Since many consumers categorize orthodontics as a want, they will mentally place orthodontic treatments in a luxury category. Until all consumers view braces as a necessary commodity, high-end orthodontic providers can establish higher pricing mechanisms than their competitors. Brands that evoke emotions will thrive over their competitors.

–––––––––––––––––– Brands that evoke emotions will thrive over their competitors. –––––––––––––––––– Although we may be the last to admit it, humans are highly emotional when it comes to making purchasing decisions. According to Buy Ology, neuroscientists calculated that 90% of American purchases stem from emotional impulses rather than logical (Lindstrom 2008). Regardless of all the data and logic present in a consult, the underlying reason behind the purchase can be attributed to emotion. What emotions are you as a doctor tapping into that allows you to charge higher fees? 1. If parents are perceiving orthodontic service as a necessary commodity, their orthodontist has failed as an educator. Depending on the relative importance consumers place on orthodontic treatment, they may be looking for the premier provider through the brand and the reputation of the doctor. 2. Relative differential pricing triggers a subconscious valuation of the product or service, regardless of additional observations. The higher the price, the

more value consumers will associate with the product. According to Stanford’s wine experiment under behavioral economic studies, higher priced wine tastes better to consumers than lower priced wine, even when the two bottles are filled with the exact same wine (the wine labels were changed during the study). Perception can measurably alter consumer utility. This can also be true of an orthodontic clinic, as long as the experience within the practice accommodates the higher price. TRIGGERS: In your own office, observing the patients rationale for decisions can give insight on how to close the sale. If the patient appears to be triggered by fear, then warning them about the future consequences of not treating their malocclusion will appeal to them. Triggering alarm will compel patients to behave urgently to avoid negative consequences (Hogshead 2010). On the other hand, a patient motivated by positive emotions would be drawn in by the benefits of having their malocclusion improved and a beautiful smile. STORIES: People LOVE stories. Exceptional stories will sell both you and your service by triggering emotion from within the listener. Connecting to patients through the stories can raise them to the next level and take them one more step closer to purchasing. Stories sell- what’s yours? LOSS LEADER: According to socialpsychology expert Robert Cialdini, people feel obligated to do something in return after someone does something for them. Therefore, loss leaders such as, “free consultation” or “free whitening” will help bring people into the office and incline them to choose your office over others. Frequently, a single orthodontist or clinic may be well known for supporting their local community. Their support may not be any different than other doctors, but they have better public relation departments promoting their contributions.

Q1 • 2017 | TheProOrtho.com 13


BUSINESS & PRACTICE DEVELOPMENT PRICING: The brain is incredibly complex, and there are a multitude of signals that give off clues as to the value of a good or service. How do you know how much a house is worth until you look at the other homes in a neighborhood? The price your patients are willing to pay can be partially explained by the framing effect.

–––––––––––––––––– People tend to gravitate towards the middle-priced item, so a more expensive service will make the traditional treatment seem less expensive. –––––––––––––––––– The framing effect states that purchasing decisions can be altered on the basis of their relative attractiveness or presentation (Kahneman 2011). When Williams Sonoma released the breadmaker, they offered two prices: $80 and $120. Williams Sonoma found that consumers gravitated towards the least expensive breadmaker, for $80, so they decided to introduce a premium loss leader: a $475 breadmaker. Consumers were then faced with three options: $80, $120, and $475. Predictably irrational consumers were affected by the introduction of the $475 bread maker as sales of the $120 breadmaker increased (Ariely). This type of framing has been applied in successful orthodontist places where they use lingual brackets at a fee that is substantially higher than

14

traditional practices. They also may have a partial-treatment fee that is less than a traditional fee. Our brains tend to quantify value through the framing effect. How can this be used in your own clinic? Just like Williams Sonoma, the framing effect can be applied to orthodontic practices offering differentiated priced services (such as lingual brackets). For example (Colgate 2016): ▶ the average price of braces is about $5,000 ▶ the average price of clear braces is about $6,000 ▶ the average price of lingual braces is about $9,000 The way that orthodontic services are priced will influence the quantity of money patients are willing to pay. People tend to gravitate towards the middlepriced item, so a more expensive service will make the traditional treatment seem less expensive. In this example the number of patients to sign up for clear braces will likely increase if a higher priced item is available. SALES: The sales process itself is vital in consumer decisions. Aside from fees, people tend to do business with the practice that they perceive is the one that has the patient’s best interest at mind. What is the experience like, aside from the product? Let’s take coffee as an example. Consumer Reports and A&G conducted blind taste tests that suggested cheap coffee like McDonald’s and Dunkin’ Donuts is actually preferred to the expensive Starbucks coffee (Bloomberg, Seattle Times). If consumers prefer McDonald’s coffee in blind taste tests, then why pay more money for a cup of

It’s just BUSINESS

Starbucks coffee? It comes down to how the coffee is sold: the Starbucks brand is associated with superior quality, while the McDonald’s brand with insuperiority. In the coffee market, consumer’s purchasing decisions may reflect a brand stereotype rather than their actual taste preferences. Even so, the Stanford Wine Club experiment demonstrates that even the presence of a stigma of quality will change the way consumers enjoy a good. Starbucks charging higher prices for the experience from the moment you walk into the door. The Starbucks ambience is saturated with dim lighting, a boutique menu, and even European sounding drink

–––––––––––––––––– In other words, everyone who interacts with patients- from the receptionist, the financial planner, and the assistant- has a sales job. –––––––––––––––––– sizes. The drinks are not small and large: instead they are tall and venti. Starbucks creates a coffee experience unlike any of its competitors, so consumers are no longer comparing apples to apples when they look at the Starbucks coffee prices. Comparing Starbucks coffee to McDonalds coffee is like comparing apples to oranges in the eyes of many consumers. Competing clinics will charge lower prices than your clinic, but your clinic can use product differentiation to become properly distinguished in the eyes


BUSINESS & PRACTICE DEVELOPMENT of consumers. How can you apply the Starbucks quality in your own office? Just like Starbucks, recognize that the experience of every part of your office is included in the product itself. Harvey Mackay, internationally recognized sales coach and author of seven NY times best selling business books, treats every experience with the customer as a sale. Mr. Mackay’s motto is, “everyone is in sales” and he often says that the sale begins when the consumer says yes. In other words, everyone who interacts with patientsfrom the receptionist, the financial planner, and the assistant- has a sales job. If patients leave your office happier than when they walked in, they will rave to their friends and family about how wonderful your office is. Money spent on a patient’s care does not provide the same rewards as time and effort involved in customer service training. The customer service level is associated with the quality of the product: consumers will associate high-quality customer service with high-quality products and services. The majority of Starbucks drinkers probably think that their coffee tastes better than McDonalds, which can be attributed to their experience at Starbucks. Many competitors are often too preoccupied with day-to-day operations to touch the lives of their patients, so be the pioneer that leads endeavours towards the enhancement of orthodontic care. COMMODITY EFFECT: When orthodontists sell their services as a commodity, they will generally adjust their fees to compete with pediatric providers and PCDs. In the education and sales process, it is vital that time is spent differentiating their services from competitors, especially if they are competing with an office holding lesser credentials. When consumers are properly educated, they will perceive more value in orthodontic treatment provided by a qualified doctor. FAMILY: Nothing consumes parents minds more than their children. The

majority of parents want the absolute best for their children. Through the education process, parents will often spend more on their children than they would on themselves. What products are your customers walking in with? Do they have apple products and nike shoes? If someone believes for a moment that price is the most important factor for the stylish families that walk in your clinic, then they are not in sync with the parents. Wal-mart and Target have plenty of knock-off shoes, but many parents today are spending more on products for their children because they want their children to have the best. Parents truly want the best for their children when it comes to education, college, and (yes) even braces. Orthodontists have more education, experience, and qualifications than many of their competitors, so it is up to them to show families what they can offer them above and beyond other treatment alternatives. In conclusion, there are numerous ways to tap into the latest discoveries of neuroscience and apply them in your own office. The mind is extraordinarily complex, so understanding the way patients think will help you and your clinic thrive, despite the challenging influx of competition. Sources: Ariely, Dan. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper, 2008. Print. Cdn Market Review. “The Price of Oil and the State of the Economy.” CANADIAN MARKET REVIEW. N.p., 16 Jan. 2015. Web. 12 Nov. 2016. Cialdini, Robert B. Influence: Science and Practice. Boston: Pearson Education, 2009. Print. Conlon, Christopher T. and Rao, Nirupama, The Price of Liquor is Too Damn High: Alcohol Taxation and Market Structure. September 15, 2015. NYU Wagner Research Paper No. 2610118.

Elin McCoy - August 27, 2009 00:01 EDT, Elin McCoy. “Paris Hilton’s Prosecco Cans Send Italians Into Fight Mode.” Bloomberg.com. Bloomberg, n.d. Web. 17 Dec. 2015. Girgorian, Vadim. Russian Standard Vodka: Strategies for Global Branding and Expansion into the US Market (n.d.): n. pag. Instead: The Business School for the World. Web. Hogshead, Sally. Fascinate: How to Make Your Brand Impossible to Resist. New York, NY: Harper Business, 2016. Print. Jain, Payinka. “5 Behavioral Economics Principles Marketers Can’t Afford to Ignore.” Forbes. Forbes Magazine, n.d. Web. 18 Dec. 2015. Lindstrom, Martin. Buy Ology: Truth and Lies about Why We Buy. New York: Doubleday, 2008. Print. Kahneman, Daniel. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011. Print. Louw, Leanie, et al. “Optimisation of the Partial Napping Approach for the Successful Capturing of Mouthfeel Differentiation between Brandy Products.” Food Quality and Preference 41.2 (2015): 245-253. Print. Phillips, Kelly. “Are Taxpayers Paying for Free Cell Phones?” Forbes. Forbes Magazine, 12 Feb. 2012. Web. 12 Nov. 2016. Sandilands, Tracey. “What Is the Average Cost of Braces in 2014?” What Is the Average Cost of Braces in 2014? Colgate, 01 July 2014. Web. 12 Nov. 2016. Seattle Times Staff. “A Bitter Shot for Starbucks: McDonald’s Wins Taste Test.” The Seattle Times. N.p., 03 Feb. 2007. Web. 18 Dec. 2015. “Winner in the Battle of the Brews: Dunkin’ Donuts Beat Starbucks.”Bloomberg.com. Bloomberg, n.d. Web. 18 Dec. 2015.

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H.R. INSIGHT

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It’s just BUSINESS


H.R. INSIGHT

CONDUCTING A CANDIDATE SITE VISIT; WHAT YOU NEED TO KNOW By Shannon Patterson Earlier this year I had the opportunity to attend an intensive physician recruitment program, and I attained credentials as a certified medical recruiter. The experience was eye-opening, and I walked away with much more knowledge on how to recruit and retain candidates for orthodontists. Over the last decade, we witnessed a significant shift in the physician employment model as the medical market consolidated. According to Merritt Hawkins 2016 Survey of America’s Physicians, research data indicates that, in 2016, only 32 percent of physicians describe themselves as independent practice owners or partners, down from 34 percent in 2014, 48 percent in 2012 and 62 percent in 2008. These responses clearly demonstrate the evolution of medical practice away from the traditional private, independent practice model and toward the employed model. With that shift, hospitals have become creative and innovative in ways to attract candidates to their communities. Whether or not we will see this shift ever happen in the dental market is unknown,

but we can take away some key insights on how to attract and retain associate orthodontists in our practices. First and foremost, recruitment and candidate selection requires: • that you develop a plan to help identify the need for an associate (needs assessment) • the requirements of the position (what you expect from an associate) • how to market for the position • understanding how to choose and select the most appropriate candidate for the position The second part of the equation is candidate retention, as this will ensure that your investment will continue to stay in the practice and the community, especially if the candidate has no path to equity. How will you keep this candidate in your practice? Understanding the importance of identifying a candidate with not only the right clinical skill set but also determining how this candidate will fit into your practice and culture is key to long-term retention. The average physician will typically have

three employment/associate positions during their career. Most candidates’ first career choice has to do with finances due to student debt obligations and lasts approximately 2.4 years. Usually, their second employment opportunity is their longest commitment as these are the years they want family stability as they raise their children. Finally, their third position many times is a semi-retirement position that puts them closer to their families or geographical preferences. So what have we learned as we have witnessed the shift in the physician employment model? For starters, once you have identified the need for an associate, you will need to understand how a candidate will fit into your community and your practice culture. You will need to convey to that candidate why they will be a good fit and flourish in the practice. The most important question for you is will a candidate be compatible with your practice and community culture? The compatibility between you and the associate is essential as an associate can have either a positive or negative impact on the growth of the practice. A strong interview process will ensure the recruitment and retention process will be a success. To accurately assess candidates for the position, be sure to identify the candidates family ties, values, cultural beliefs, hobbies, social factors/behaviors and, most importantly, engage the spouse/partner during the process. Together these insights will help you engage and build a relationship with candidates both professionally and personally, which will increase the likelihood that you keep candidates in the practice and the community long-term. A critical part of the process of the candidate selection is the site visit. At

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H.R. INSIGHT • Will I have an opportunity for equity? • How many patients will I see per day? • How many days per week am I expected to work? Hours per day? • What kind of benefits will you offer? • Will there be incentives for income growth? • Who/What are the referral sources? • What percentage of your patients are adults? • Will my voice be heard regarding practice management? • How do you market to patients and referring doctors?

this point, you have invested a significant amount of time getting to know the candidate over phone interviews. The days of ‘meet me at the office after 5:00 when the staff is away’ are long gone. A candidate expects and needs to meet with you and see your practice in action, get a feel for the staff and how supportive they will be and, most importantly, assess the community. There’s no second chance to make a good first impression. That’s why it is important that when you schedule a candidate site visit, you do it right from the start. Over the last few years, we have gathered post-site-visit interview surveys from candidates and below are some helpful “dos” and “don’ts” for hosting a successful candidate’s site visit. It is crucial to understand the candidate will want both personal and professional information about the opportunity to evaluate the practice as well as the community it serves. You will need accurate and up-to-date information about your state, county and city demographics to provide to candidates. It is important to address candidate’s personal and family interests before scheduling a site visit to your practice and community.

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It’s just BUSINESS

QUESTIONS TO EXPECT FROM CANDIDATES ABOUT THE COMMUNITY INCLUDE: • What is the population size of the community? • What are the demographics of the community? • What are the cultural, recreational and entertainment venues in the community? • How is housing availability? Affordability? • What are the school ratings in the community? Include both public and private. • Where is the closest international airport? QUESTIONS CANDIDATES MAY HAVE REGARDING THE PRACTICE INCLUDE: • What is your practice culture? • What is your practice philosophy? • Will you act as a mentor? • Do you have a vested interest in my future and success? • Will the position have a guaranteed income or production based pay incentive? • Non-competes: what are the restrictions and distances?

QUESTIONS YOU SHOULD CONSIDER ASKING A CANDIDATE BEFORE SCHEDULING A SITE VISIT INCLUDE: • Why are you considering our community? • Do you have family in the area? • What are your hobbies? • Gently inquire about values and beliefs. • Will you live in the community or commute? • Will your spouse be looking for employment? • What are your income expectations? • Why are you leaving your current practice/opportunity? • What is your five-year plan? So you have identified a candidate you think will be an excellent addition to your practice and you have invited them to visit the practice, what’s next? Once you have the date selected to host a candidate, it is time to prepare an itinerary. The site visit is time-consuming for both parties, but it is the most crucial part of the decisionmaking process for the candidate. It can be extremely valuable to create a team to help cultivate a positive and memorable experience for the candidate and their spouse/partner. I can’t stress enough that if a candidate has a significant other to include them on the site visit, we all know a happy significant other ensures a candidate’s long-term retention. If you can woo the spouse/partner, they can become the biggest advocate of your


H.R. INSIGHT practice opportunity. Your team can and should include someone who is similar in age to the candidate; this can be you, your spouse, a team member, or a referring doctor in the community. A candidate will connect with someone in their age group who lives in the community. A well-constructed itinerary will be the difference between an excellent and mediocre visit for candidates. We have learned it can be beneficial to host a candidate for two or three days often including a weekend. We suggest you offer a candidate the opportunity to observe you engaging with patients during clinical hours, a dinner including spouses and possibly referring doctors close to their age, a community tour, and allow private time to explore the area on their own. Currently, it seems the candidate pool is smaller due to the growing corporate footprint in the dental market. Residents are being recruited earlier in their programs and lured with big money. Therefore, it is important to showcase what you and your practice have to offer a candidate. Don’t be afraid to roll out the red carpet for a candidate. It can make them feel valued right from the start. Offering to make and pay for reservations and arrangements during the visit can make a big impression with a candidate. Be sure to identify accommodations that represent your community well, and if there are none, consider making arrangements for them to stay in a private home. If a candidate has never been to your area, it can be beneficial to have a car service meet them at the airport and provide transportation to his/her destination. This will influence how your candidate may see the community for the first time allowing for a positive experience. Remember you have received all of the information from the candidate about what he/she desires in a community, so be sure to showcase and highlight those areas of interest. If they enjoy running, show them the running trails, the local running clubs. If it’s golf, show them the courses and make arrangements

to have lunch at the club. Just be sure to showcase what they desire and not highlight your interests. If they have school-aged children, show them the schools in the community. If applicable, provide the candidate a list of local places of worship. It can also be helpful to identify a realtor who can give them a tour of the neighborhoods, showing both properties for rent and sale that will meet their financial needs. Split tours can also be beneficial if the candidate has a spouse/ partner. While the candidate is with you in clinic, their spouse can be touring the community with your spouse, team member or realtor. Be sure to share the itinerary with the candidate and get his/her feedback and insight for the agenda before the scheduled visit. Providing the agenda to the candidate early allows him or her to review and understand your expectations during the site visit. Be mindful to include all the addresses and contact numbers for the candidate on the itinerary. Ensuring a candidate feels welcome and comfortable in your practice and community is crucial, so pay attention to details. Often small but special incentives like customized gift baskets, local gift products, and car rentals with preprogramed GPS maps can make a huge impression on the candidate. So, you have had a successful visit with

the candidate and you know they will make an excellent addition to your team, what do you need to do next? This can be the most critical point of the visit. The most direct approach is to have a letter of intent (LOI) to offer the candidate. Hopefully, during the phone interview process, your conversations led to an idea of the candidate’s income expectations and what it will take to get them on board. Having the LOI or offer waiting for the candidate at the end of the visit will make it clear to the candidate how much you want him or her in your practice and it gives you the opportunity to gauge the candidate’s interest level. If you decide to wait to make an offer, make sure to provide the candidate an offer soon after the visit. Quality candidates are going to continue their search and could be engaged with another opportunity soon. One thing I have learned for sure is if you have identified an exceptional candidate, chances are someone else has too! Understanding the importance of the site visit during candidate selection can help you stand out from other opportunities. If you provide an exceptional experience to the candidate by addressing all of his or her questions and concerns about the practice and the community, you show the candidate that you have a vested interest in his or her future!

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WHAT SETS US APART IS HOW WELL WE BRING EVERYTHING TOGETHER. And everything we do is for you and your patients. We’ve invested millions in building the Invisalign® brand and the technology that helps transform practices and lives. Each Invisalign treatment is unique, just like your business, and together we can help discover new ways to grow both. Grow your practice today at Invisalign.com/provider.

© 2016 Align Technology, Inc. All rights reserved. Invisalign® and Invisalign Teen®, among others, are registered trademarks of Align Technology, Inc. M20474 Rev A


BUSINESS & PRACTICE DEVELOPMENT

The Plastic Employee By Dr. Jonathan Nicozisis

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– You may delay, but time will not and lost time is never found again. -Benjamin Franklin

Employees engage with employers and brands when they’re treated as humans worthy of respect. – Meghan M. Biro

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– MINDSET Having evolved as a specialist who ‘does orthodontics with Invisalign,’ rather than simply an orthodontist that ‘does Invisalign,’ my confidence and ability to treat the majority of case types and solving certain tooth movement once thought of as impossible with aligners only is profound. As such, my share of chair in 2016 is hovering around 70% +/-. While I will continue to expand and increase this percentage, over the last few years, I have focused my efforts in truly realizing the business and practice management impact Invisalign has had in my practice. After mining and reviewing this information, I came to realize that the Invisalign System is more than an orthodontic appliance that once was the Rodney Dangerfield of appliances. Rather, as a business owner and employer, I unknowingly engaged it as I would an employee, and it has since earned the respect it deserves not only as a valid orthodontic appliance system but also a true business partner. In 2003 the Invisalign mindset was that it is an alleged orthodontic appliance with limited application. The 2016 Invisalign mindset is (or should be) it’s a practice business partner primarily first

and an orthodontic appliance second. Continuing, Invisalign is a Business partner, a Practice Consultant, a new digital workflow within a practice, Schedule Optimizer and more profitable than braces!!!! What I am boldly talking about is a fundamental shift in changing your practice to one this is an aligner modeled practice and not a practice based on braces. What is evident is that aligners have grown to make up well into the mid to upper twenty percent of the orthodontic market. With a marketing capitalization of almost $8 Billion, Align Technology is not going away! You might delay, but time and others in your area will not and have not, and have been benefiting from the market demand and have been growing their business. KNOWLEDGE My primary practice has been in existence for over forty years, and I have been a part of it for the past sixteen. It is often difficult to move the production needle in these types of mature established businesses. In 2012, a long time chairside employee sustained an injury outside of work that prevented her from returning and rendering patient care in her normal capacity.

In 2012 my average production per employee was 230,000. The JCO and practice consultants report that the average production per employee in an orthodontic office ranges from$180,000 to $200,000. Fast forward to the end of 2015 and compared to 2013 (my first full year with one less employee), I have one less employee, an increase in the yearly number of comprehensive treatment case starts by 33%, and an increase in production of 35% with an average production per employee at 381,000. Furthermore, there are a heck of a lot fewer emergencies and a greatly improved patient experience lending itself to positive feedback of referrals of family and friends unlike I has previously experienced with braces. It’s as if this ‘critical mass’ has been surpassed resulting in a perpetual snowball effect of happy patients using plastic to address their concerns referring more and more people to our office. For the first half of 2016, with the same number of staff, my comprehensive phase 2 starts is up 22% compared to 2015 and production (meaning the same as collections or deposits in the bank) at the end of June is up 16% compared to 2015. And this with my partner retiring and working half the number days since Jan

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BUSINESS & PRACTICE DEVELOPMENT

1st, 2016. That metric of average production per employee is worthy of further reflection. Let’s make some assumptions to drive home the point. As per the JCO, the average production per employee in an orthodontic office is $200,000. Compared to 2012, in 2015, I increased my annual number of starts by more than 70, all of them Invisalign in comparison to the number of fixed. Actually, the total fixed is decreased, but the overall total number of annual starts has increased by more than 70 starts from 2012. For the sake of this example, I will use 50. Compared to two years ago I have one less employee and her salary was around 53-55k per year in total with all benefits, etc. So my $200,000 in production costs me 54k to get. My lab fee discount based on case volume is 34% bringing the cost down to 1060 (full)-1122(teen)…. let’s average it to 1091 per case. 50 cases at 1091 lab fee per case = 54,550 lab fee versus staff salary of 53-55K per year.

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Now let’s apply some different case fees to these new starts: 50 cases at 5500 fee = 275,000 50 cases at 6000 fee = 300,000 50 cases at 6500 fee = 325,000 So based on the same ‘cost’ for a salary compared to a lab fee I’m able to generate an additional 75,000-125,000 in revenue with less chair time and fewer emergencies. Also, let’s not forget the improved patient experience that refers new patients to me! Also my lab fee is part marketing fee that also helps drive people into my office whereas my bracket company does not. In fact, there is no other company in our industry that not only makes the public aware of Invisalign, but also orthodontics in general. Finally, the plastic employee does not call in sick, does not ask for time off, does not ask for a raise, does not take vacation, does not have its health insurance premiums raised by double-digit increases every year, and is not subject to FICA taxes. Actually, the plastic employee did ask for a slight raise last year. Six months

It’s just BUSINESS

before they did, however, the plastic employee came to us with a solution that we did not know we needed, but certainly improved the way we could practice and that was five years of unlimited aligners! Now I can start using Invisalign in younger patients for phase 1 if needed not worrying about the case expiring. This opens up a whole new avenue of making my office distinct in my area by offering Invisalign for phase 1 treatment when appropriate. So the Plastic Employee, when engaged and treated with the respect like a human, actually has the capability for not only an increase in productions for the same cost as an employee, but also helps market my practice and drive people to it while increasing the capacity to treat more patients within the existing number of patients hours each week. Like any good business, I learned how to do more with the same or really less. Let’s look at another perspective to help answer the questions, ‘Why bother treating patients with Invisalign? Why increase your usage of Invisalign to treat your patients?’ The goal is to drive more


BUSINESS & PRACTICE DEVELOPMENT new patients to your office. I realize and hear the complaints of the ‘cost’ of treating patients with Invisalign. According to The McGill Advisory Newsletter 9/2010: ‘We asked doctors if they were operating at optimal (100%) capacity defined as being as busy as they wanted

––––––––––––––––––– Invisalign scans is saving me money. Back in 2012 when I first got one, I was saving about $7000 plus a year. Now with my increased volume of cases, I can estimate that I am saving about $13,000 or more by not buying impression material. ––––––––––––––––––– to be and thus did not need to increase patient flow. Overall, only 9% of the 383 doctors responding indicated that they were operating at full capacity down dramatically from 17% in 2007. Orthodontics had the fewest percentage of doctors operating at full capacity at only 6% down from 9% in 2007 So in 2007, still 91% were not operating at capacity More so, in 2009 94% were not operating at the desired capacity 56% of orthodontists admitted that they were operating at less than 80% of capacity Orthodontics remains the least busy of any segment of dentistry with the average orthodontist operating at only 77.61% of capacity down from 81.52% in 2004. Six -ear trend ( from 2009): Every

segment of dentistry is spending more on advertising and marketing compared to our 2004 survey. Orthodontists led the way spending 2.92% of collections in 2009. This means if you gross one million a year you should be spending $30,000 per year in advertising… … or $2500 per month …or $625 per week Wouldn’t it be great to have someone share in the cost of this?!?!?!? What is interesting is that in 2016, the same newsletter published very similar numbers from asking the same survey. So not much has changed in six years by way of us being at capacity. So in reality, there are always holes in the schedule to fill which means they can be filled by any patient. While profitability per visit is one metric to look at when treating a case, it really does not hold a lot of weight if there are holes in the schedule. Over half of orthodontists are not operating at capacity. So the goal is to drive new patients that would normally not seek treatment to the office in the first place to fill these holes in the schedule that the McGill Advisory Newsletter Survey indicated that we all have in our schedules. Using the metric of 3% of production should be spent in marketing, that means the 3% of my $6500 fee is $195. Let’s round up to $200. Thus $200 of my $1729 lab fee is allocated to the marketing that Align does for me. Hence my aligners now cost me $1529. If you apply my upfront rebate reduction of 34%, that means that you can reduce $587.86 off my $1529 fee, leaving a net fee of $941 for aligners. How does that figure to Insignia? How does the patient experience compare to braces? How does the chair time compare to braces? How do the number of emergencies compare to braces? iTero has been another game changer the goes directly to improving the

bottom line. Prior to getting one, I was spending $1000-1300 a month on PVS material. Today, I’m sure it would be closer to $2000 or more. Financing it at about $600-700 a month for unlimited Invisalign scans is saving me money. Back in 2012 when I first got one, I was saving about $7000 plus a year. Now with my increased volume of cases, I can estimate that I am saving about $13,000 or more by not buying impression material. The other reality is that a lab fee is still a lab fee, and we cannot escape that, but like anything else in life, you have to spend money to make money. Or as described above, perhaps consider shifting and reallocating overhead from the salary column to the lab fee column due to the increase is production per unit of cost. So you need to focus and promote the other tangible advantages Invisalign has to offer

––––––––––––––––––– Thinking like an accountant makes one instinctively think about costs and overhead. Thinking like an economists makes one think about the future and risk and being risk adverse as the future becomes the present. ––––––––––––––––––– so that at least you can counter this lab cost issue and feel as if you ‘break even’ on each case. SKILL You must commit to mastering doing orthodontics with plastic! You are the orthodontist! The software is not, and neither is the technician. Thus, you must

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BUSINESS & PRACTICE DEVELOPMENT

NOTE #9 : G4 SECOND ORDER ATTACHMENT WOULD NOT BE APPLIED BECAUSE OF THE LINGUAL RETRACTION.

think like an orthodontist when designing your clincheck. Think of a tooth’s initial position, where it needs to go and then how you can design force systems to push against the crown to elicit moments that will translate up through the center of resistance to achieve the desired tooth movement. So if you now you need a G4 second order attachment on #9 for mesial root tip but the software will not allow it because there is lingual retraction of the incisal edge. Currently, this lingual retraction negates the thresholds that must be met for the software to apply G4 second order attachments. Hence, you must think outside the box! You must apply your skill as an orthodontist knowing how teeth respond or need to respond to forces and design a twin attachment to create pushing surfaces to elicit the moment needed to apply mesial root tip. EPILOGUE Ben Burris once asked me the simple yet profound question, ‘Do you think like an accountant or an economist?’ Thinking like an accountant makes one instinctively think about costs and overhead. Thinking like an economists makes one think about the future and risk and being risk adverse as the future becomes the present. I think I have addressed both these perspectives in this article. I have shown how a fundamental shift in modeling your practice on aligners can be more productive and efficient from an accounting point of view. As an economist worried about the future, I think it is vital for me (and I would argue most every ortho) to be adept at doing orthodontics with plastic. Aligner therapy is not going away. Its market share will only continue to grow. You may delay, but time will not and lost time is never found again. ‘I want straight teeth, and I want to wear braces’ –Said No One Ever.

AFTER TREATMENT

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It’s just BUSINESS


It’s Time to Demand More From Your Supply With MidAtlantic Ortho’s new E-Commerce marketplace, we provide a 24/7 on demand resource for all of your practice supply needs. More than online ordering, MAO now provides a user friendly way to place, track, and store your purchase and ordering history with just a click of a button. With MidAtlanticOrtho.com, you are free to start and treat more patients instead of waiting on your sales representative, buying more than you need, figuring out a complicated group program, or stressing over your supply. Over 100 years of orthodontic marketplace expertise, bringing leading manufacturers to your fingertips – 24/7. Supply that supports your Bottom Line.

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MARKETING, SOCIAL MEDIA & EVENTS

Help for Yelp, Protect Your Reputation By Dr. Dovi Prero and Dr. Sheldon Salins

What do you do when you get a “onestar review on Yelp”? Orthodontists must be aware of their online reputations and the impact it can have on their practice. Patients first search online to find a dental provider or at least do their research about an orthodontist who has been recommended by a friend or dentist. As business owners, a strong reputation with excellent reviews can help patients find us and guide their decision to determine if our practice is the right fit for them. We all put great efforts into creating a friendly environment and do our best to put the customer first and “Make Them Happy” - (Neal Kravitz). Once in awhile, though, a patient can have a less than ideal interaction with the practice and when a review is written that is not five stars, what do you do?

REPLY Second, respond to the negative review from your account. Address the patient’s concerns and write a personalized message. All consumers know that not everyone will have the same things to say about a business. However, if the business responds respectfully and tells your side of the story, the customer can see that the business is attentive and cares. This in and of itself is worthy of your time. Make sure it’s not a standard response apologizing, blaming HIPAA on the lack of a concrete response and provide your number to discuss the situation.

LOGIN First, you must have a Yelp BUSINESS account. http:www.biz.yelp.com. Claim your business and create an account. You need to be logged in to your business for step 2.

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It’s just BUSINESS

REPORT Third, you can click the Flag button on the lower right-hand corner under each review and ”Report The Review.” Remember, you need to be logged in to even see this option. Also, you can report a review on your own page or a page of your colleague too. This means that you are asking Yelp to assess the content in the review to see if it violated the guidelines. There are eight reasons you can report the review and select the one on the drop down menu (pictured below).


MARKETING, SOCIAL MEDIA & EVENTS –––––––––––––––––– This nuance is probably more successful when someone who is not the actual business owner reports the review. It will appear to be less biased. –––––––––––––––––– After selecting the reason to report you can provide additional details. Let’s discuss an actual review. Rockstar Dr. 1 treated Johnny to a satisfactory result during his teen years. When Johnny is in college, he notices his teeth have shifted and seeks a second opinion from Dr. 2 about his teeth. Dr. 2 mentions to Mom that the braces were “taken off too early” and that he needs treatment again. Mom calls the office of Dr. 1 and is frustrated and wants to speak to the doctor. The front desk tells Mom that the patient is an adult and the consultation fee is $250 for the adult consultation. Mom hangs up in anger and goes immediately to yelp and writes a 3-star review for Dr. 1. She includes the details about Dr. 1 took the braces off too early on her son, and they were even going to charge her for the consultation. The review stays up for three months and causes Dr. 1 and his staff

frustration. After all, they do their best to provide 5-star service. So, I saw this review on my colleague’s Yelp page. Reported it and selected from the drop down “It doesn’t describe a personal consumer experience.” In the additional details section, I wrote that since the Mom was writing the review about her frustration and the son was the patient this violates the review guidelines and should be taken down. I received an automated response from Yelp right away saying they would look into it. Two days later it was taken down, Yelp sent an email confirming as such, and the office was relieved. This nuance is probably more successful when someone who is not the actual business owner reports the review. It will

appear to be less biased. The best way to deal with negative reviews is to prevent them. Provide amazing treatment and service and encourage your patients to share their experience on review sites. In this case, the fee for the consultation may have been the tipping point to Mom. And the practice probably should have provided a complimentary consultation for an existing patient if they had gathered all the information when Mom had called. The creators of Yelp, Facebook, and Google are much smarter than any of us. However, If you understand that Yelp is a game here to stay, you need to learn how to make the game work for you. Then, and only then, you can play to win!

Q1 • 2017 | TheProOrtho.com 27


BUSINESS & PRACTICE DEVELOPMENT

A Clear Path to Effective Business Planning By Sarah Sharfstein, MBA, Director, Marketing North American Ortho The orthodontic marketplace has seen a tremendous amount of change in the last five to ten years, all of which is happening at a rapid rate. To stay competitive and relevant in this environment practice owners must increase their business acumen and improve the way they evaluate how their business is positioned for future growth. This sounds easy, and it is—if you have the requisite skill set! ANALYZE YOUR PRACTICE DATA A successful orthodontic practice has well-defined goals, yet is agile enough to adjust these goals and strategies as necessary due to shifting market trends. To be nimble enough to prosper in an ever-changing environment requires constant analysis of data in real time so that any necessary course correction can be performed sooner rather than later. One best practice is to look at your data several times a week (if not daily). Data analysis tools such as Gaidge have become critical for this process and can aid in the operation of an efficient and profitable business. Below are several “practice points of interest” questions to be asking yourself while analyzing your practice. PRACTICE GROWTH ▶ From what segment of the population is your new patient growth originating? • If it is adult patients, is it because you are offering faster and more esthetic treatment options? • If it is Phase I, did you conduct a campaign to promote the proper age to be seen? If so, what is its cost and what is your return on investment (ROI)? • If the vast majority of your starts are

28

traditional patients (teens and tweens), are you missing out on huge opportunities in other segments? ▶ If you were to modify your pricing or financial arrangements, would it be possible to start more patients? Would you have to work more to do so? At what expense? ▶ Are there certain segments of patients that you would like to target? If so, do you have a game plan around how to attract them? CONVERSION RATES & RECALL ▶ What is your practice’s average conversion rate, and how do you calculate it? • Conversion rate is simple. It’s calculated as the total patients who start treatment divided by the number of patients to whom the doctor prescribed treatment. • Does your conversion rate differ between children, teen, and adults? What about from treatment coordinator (TC) to TC or associate to associate? • Are your stats accurate? How do you know? ▶ What percentage of patients BSF a Same Day Start? Why? ▶ Do you have a clearly defined process for recall and your observation pool? ▶ How do you KNOW your recall is being followed up? SEASONALITY ▶ Do you have seasonality in production and collections or just production? Why does it matter? • Many orthodontists accept that certain months are slow because they have always

It’s just BUSINESS

been slow. Once you have identified these trends, it is easy to build a campaign prior to these months to drive growth. PEOPLE, PROCESS & PRODUCT In addition to practice data, you will also want to consider qualitative factors such as people, process, and product, that can have a serious impact on your practice. PEOPLE Do you have the right people in the right positions in the office? Is your front desk friendly and inviting? Is your TC a stickler for patient follow-up and does she believe that the best way to convert a patient is by selling an experience, not just braces or Invisalign® aligners? In the clinic, is your team as efficient as possible? Are there clearly defined systems and processes? With the introduction of acceleration and weekly aligner changes during Invisalign treatment, I continue to be amazed at how few offices are making a shift in their clinics or see this as an


BUSINESS & PRACTICE DEVELOPMENT opportunity to do more with less. For practices seeing patients less frequently and for a shorter amount of time, each visit provides a huge opportunity to make this new-found free time in your schedule more effective AND efficient. Human capital is often the most expensive line on a practice’s Profit & Loss Statement. When evaluating your year, if you have increased efficiencies substantially, it might be worth repurposing a clinical team member to a role that allows for revenue generation. Some ideas that come to mind are marketing or an observation coordinator if you have a big enough Phase I pool. I was recently in a practice that does quite a bit of Invisalign treatment and just recently made the jump from roughly 20% of their patients in aligners to more than 40%. They had just been given a resignation from an assistant and were in the process of composing an ad for her replacement. Initially, the practice owner was planning to re-hire for the same role because the office always had six clinical assistants. After reviewing several of the changes in the practice, it was obvious that, with the increase in Invisalign production, they did not need the additional clinical assistant and the role of this assistant was starting to look different than it had in past years. This is a great example of what Jonathan Nicozisis calls the “Plastic Employee,” and the decreased need for staff is a great benefit of seeing patients less often, finishing faster, and having

fewer emergencies. This new assistant is doing a ton of digital scans, bonding of attachments, and spending more time engaging patients in the chair to drive a better experience, and, in turn, referrals. Given the shift in practice approach, hiring for personality and the ability to connect with patients slowly becPNFT more important than technical skills. PROCESS As we have seen, there is a tremendous amount of consolidation happening in the orthodontic marketplace. Practices are opening satellite locations, taking on associates, and merging with other ortho practices. As this occurs, the need to build out scalable systems and processes becomes increasingly important. As we all know, a process is only as good as the accountability mechanism put in place to enforce it. For practices purchasing general dentistry or pediatric locations with the goal of driving more referrals, these processes become absolutely necessary. One of the tools I have found to be helpful in offices who are in growth mode is a RACI model. RACI stands for Responsible, Accountable, Consulted, and Informed. Using a RACI chart reduces miscommunication and increases productivity because everyone knows his or her role in the implementation of a strategy and/or tactic. It can also help you determine if an employee has too few or too many tasks to complete or if there are any gaps in the process. (Chart 1)

RACI Chart

PRODUCT Do you know your patients’ preferences for treatment modality? How frequently they would like to be seen? How about how they would prefer to pay you? If all you have is a hammer, everything at first glance can appear to be a nail. Making sure you understand what your patients want is key. Being able to offer and deliver, with confidence, what your patients truly want is paramount. The most common question I get from doctors is, “Since I would like to do more Invisalign treatments, what do you recommend for marketing?” The most successful offices I work with do limited external marketing and yet they continue to show double-digit growth in their practices year after year and increase their Invisalign therapy. The reason for this is twofold. First, they BELIEVE in the WHY--which instills confidence in the recommendation They believe that aligners will work, they believe they can deliver a great outcome, they believe that the majority of patients will be compliant, and they believe that it is an opportunity for practice growth. When they believe with conviction, their team believes and the conversation in the new patient exam, the clinic and their community goes from casually mentioning clear aligners to passionately educating prospective patients. Second, these successful practices set goals and communicate them regularly to the team. Stating that you want to increase new patient starts with plastic is not enough. You need to clearly define

Individual Responsible

Activity

Ann

Ben

Carol

James

Ed

Manage practice social media accounts

C

R

I

A

I

Ask for 15 referral each week

I

A

R

C

C

Develop morning meeting agenda and notes

I

C

C

R

A

CHART 1

Q1 • 2017 | TheProOrtho.com 29


BUSINESS & PRACTICE DEVELOPMENT the desired starts, within what segment of your business, and in what timeframe. To be effective, these goals should be SMART: specific, measurable, achievable, relevant to the practice, and time bound.

–––––––––––––––––– As the orthodontic marketplace changes, so does the need to look at your business differently. –––––––––––––––––– CULTIVATING CULTURE In order to help the team embrace your goals, you need to affect the culture of the practice. Without a healthy culture, achieving your goals will be challenging. You must do more than define the new results you want to achieve; you must provide a new set of experiences, beliefs, and actions (i.e., culture) that will help you reach those results. Many organizations expect new actions to produce new results in and of themselves. According to the Partners in Leadership Results Pyramid model, results, actions, beliefs, and experiences are organized in tiered layers, making it impossible to move to the top of the pyramid without also moving the supporting layers as well. The logic here is that if the desired actions are in line with team members’ values and beliefs, they will voluntarily do what is needed to produce the results. Consequently, as a leader in the practice, you can help instill culture by explaining how new experiences are critical to the practice’s success and taking care of patients, shaping their sense of progress or failure in a new task.

your strategy using the ”People, Product, Process” methodology. As an example, the bracket industry has been flat at best, while clear aligner therapy continues to become a larger and larger part of the market because it is what potential patients desire to address their orthodontic concerns. The growth potential is in addressing the wants and needs of a patient population that does not traditionally seek orthodontic care. While there are many aligner systems in the market place, Align Technology has lead both in clinical excellence and brand recognition—which will continue for some time given the steep curve facing those who want to compete in this space. The fact that Invisalign aligners are valid orthodontic appliances capable of addressing the majority of malocclusions is accurate, but of secondary importance to the most successful offices. These

practice owners realize that the true value of Invisalign treatment is its ability to access non-traditional patient bases, bring new patients into the practice and deliver an exceptional patient experience. In this way, evaluating your people, processes, and products is critical to scaling a business and long-term sustainability and relevance. An orthodontic certificate and great clinical skills are certainly necessary, but they alone are no longer enough to ensure future success. Disclaimer: Sarah Sharfstein is a paid employee of Align Technology, Inc. The views represented in this article are her own and do not necessarily reflect those of Align Technology, Inc.

CONCLUSION As the orthodontic marketplace changes, so does the need to look at your business differently. Analyzing practice data allows you to implement Culture Track: The Building An Accountable Culture Track. (2016). Retrieved from https://www.partnersinleadership.com/client-service/training-solutions/culture-track/ 30

It’s just BUSINESS


Are you ready to be

Fully Engaged ?

There are tons of orthodontic study groups out there and I firmly believe that this is an excellent development for individual doctors and for orthodontics. The increased connectivity among orthodontists is revolutionizing our specialty and helping us cope with the increasing pace of change. Some of these groups are older, some are bigger and many are awesome but none are comparable to ProOrtho FE. I'm not being ugly, it's just a fact. I have been or am part of several awesome groups and if you can't get into ProOrtho FE there are several I'm happy to recommend. That being said, if you want to be at the epicenter of modern orthodontics, you owe it to yourself to join FE. You've heard the names of many of our members but there are quite a few bad ass orthodontists with killer results and monster practices that you won't get access to unless you're inside the circle of trust! FE members are serious people. - Serious about getting great results. - Serious about growing their businesses. - Serious about not sharing outside FE and protecting our geographically exclusive areas. - Serious about thriving instead of just surviving. - Serious about providing real stability for their families.

- Serious about maximizing efficiency. - Serious about sharing with and learning from fellow FE members. - Serious about thriving instead of just surviving. - Serious about having fun when we are not at work!

Becoming an FE member is not easy or cheap but nothing worthwhile ever is. If you'd like to check and see if your area is available and find out more please fill out the form on the back and return to Carrie. -Ben Burris Q1 • 2017 | info@theproortho.com | 479-238-1004 | theproortho.com

TheProOrtho.com 31


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OFFICE LOGISTICS

Is it Time to Leave the Stone Age Behind? By Dr. Christian Groth Orthodontists have always been on the “cutting-edge” of dental technology. There are several possible reasons: we have too much money, and like new toys, we think that new technology will increase our treatment efficiency, or we are trying to gain a competitive edge. Over the past several years, the latest in high tech orthodontic toys has become the intraoral digital scanners. While scanners are not new (the original scanner was introduced in the mid-1980s), more are being introduced or updated every year. The goal of this article is to give you an insight into the different scanning technologies and an overview of the current landscape. I do not intend to give my personal feelings as to what scanner is best as I believe that each office needs to evaluate the landscape and decide what scanner would work best for their particular layout and systems. A follow-up is planned to cover what I believe will be the next “big thing” in orthodontics – 3D printing. In 1987, Siemens released the Cerec 1 CAD/CAM system. This was the start of the digital dentistry revolution. While primitive by today’s standards, it was a completely novel way to treat restorative patients. It was not until 2006 that intraoral scanners began to penetrate orthodontic offices. The iTero (by Cadent) was the first independent system that allowed for full mouth scanning. Since the release of the original iTero scanner, there has been a proliferation of scanners that have a wide range of prices, form factors, and features, making the decision as to which one to purchase much more difficult.

–––––––––––––––––– While these scanning technologies differ in their technique to capture a 3D image, they all are able to produce accurate and reliable digital models. What, then, makes scanners so different? The software underneath the scanner is the true engine that drives the scanner. –––––––––––––––––– SCANNING TECHNOLOGIES The basics of a scanner are very simple and exactly like that of a traditional camera. There is an object that needs to be scanned (teeth), a light source to illuminate the object, and a capture mechanism that converts the object from analog to digital form. However, not all scanners use the same capture mechanism. The majority of scanners today use a technology known as parallel confocal scanning. This technology was introduced with the original iTero and

has been proven to be extremely accurate and reliable. Parallel confocal utilizes a filter to eliminate poor data that is out of focus, leaving only high-resolution data in the field. These scanners stitch together a series of images to create the full digital model. Triangulation is the oldest form of scanning technology and is still being used by some systems today. Even though it is the oldest form of scanning, scanners that utilize triangulation are still very accurate. The mechanism of image capture goes back to high school geometry: the angle and distance between the laser source and the sensor are known constants and the software can use the angle of reflection to determine the distance to the object and therefore the contours of the teeth. Triangulation often requires an opaquing powder to aid the scan. 3D In Motion imaging is only used by one scanner currently. 3D In Motion utilizes multiple video cameras to capture the 3D contours of the teeth with a thin layer of powder. The distance between two data points from two different perspectives allows the software to determine 3D distance and therefore a digital model can be constructed. While these scanning technologies differ in their technique to capture a 3D image, they all are able to produce accurate and reliable digital models. What, then, makes scanners so different? The software underneath the scanner is the true engine that drives the scanner. Three scanners that use the same technology can have very different user (and patient) experiences based on the complexity of the software.

Q1 • 2017 | TheProOrtho.com 33


OFFICE LOGISTICS CURRENTLY AVAILABLE SCANNERS ITERO ELEMENT The Element (Image 1) is the latest iteration of the iTero intraoral scanner. Released in 2015, the Element is a big step forward from the iTero 2.9HD. While it uses the same scanning technology (parallel confocal), hardware and software updates make the user interface easier. While the roll out of the Element proved to have a few bumps in the road, regular software updates have improved the end product immensely. One of the significant pros of the iTero scanner is the Invisalign ecosystem as it can seamlessly go from scan to ClinCheck. In addition, you will be able to take progress scans to determine whether the teeth are tracking or not. There are several different fee structures available for the Element – unlimited scans & support, support with per scan fees (Invisalign scans are always free), or per scan and no support. At $20 per iRecord scan, a relatively busy practice will want to make use of the unlimited scan option as 216 scans is the break-even point. A downside to the Element is the single use scanning sleeves. At $2.50 per sleeve, these can add up to a significant amount over time. Some may be tempted to cold sterilize them, but this is not recommended as it can affect the quality of the digital model. 3SHAPE TRIOS 3 The original Trios was released in 2013 and has gone through several updates. The most recent update, the Trios 3 (Image 2), uses the same scanning technology (parallel confocal) and has introduced HD color scanning and the “insane mode.” The Trios scan sleeves are autoclavable but must be replaced every few hundred scans. Until recently, a major barrier to the orthodontic market was the inability to use the Trios for Invisalign. At the 2016 AAO meeting, 3Shape announced that a deal had been struck to allow Trios scans to be submitted for Invisalign appliances. As of November 2016, 3Shape is in beta testing with a small number of offices and has the full intention of releasing this

34

IMAGE 1: ITERO ELEMENT

IMAGE 2: 3SHAPE TRIOS 3

IMAGE 3: CARESTREAM CS3600

It’s just BUSINESS

update to everyone before the end of the year. 3Shape works through resellers, so you won’t be able to purchase directly from them. The current US resellers for 3Shape are Henry Schein, LED Dental, and Great Lakes Orthodontics. One should understand that the difference between resellers is their ability to service the scanner. All major problems will elevate to 3Shape technical support – which is located in Europe. Simple problems are often handled directly by the resellers; however, some resellers have more experience than others which may require involving 3Shape more often if they cannot diagnose and fix the issue. CARESTREAM CS3600 The CS3500 was the first scanner available to the orthodontic market, released in 2013. The initial scanner was riddled with issues and was not something that many people felt was worthy of purchasing. Since then, the updated CS3600 (Image 3) has come a long way with regards to the software supporting the scanner. Like the Element and Trios, the CS3600 uses parallel confocal scanning technology. The form factor is the greatest attribute to the CS3600. There is no cart or laptop to lug around. It can be plugged into any computer meeting the minimum required specs. Also, there are two scanning sleeve sizes (pedo and adult – both single use). At this time, there is no integration with Invisalign. 3M TRUE DEFINITION The 3M True Definition (Image 4) scanner boasts the smallest scan wand and is the least expensive scanner on the market. The latest update to the scanner is a very compact, tablet-driven form factor (compared to the still available mobile cart model). Invisalign has accepted scans from the True Definition for some time, but the data plan to enable this feature is more expensive. A downside to this scanner is the requirement of a thin layer of powder to enable the scan. Powder is problematic for several reasons: patients don’t tend to enjoy it, if any of the teeth get wet the powder needs to be reapplied, and


OFFICE LOGISTICS if the scan tip touches the tooth often the powder will need to be reapplied. CEREC OMNICAM Cerec has made an effort to increase their presence in the orthodontic market. We all know Cerec as the CAD/CAM system for single-visit restorations. The Omnicam (Image 5) is the latest in a long line of Cerec scanners. It utilizes triangulation scanning technology and is Invisalign compatible (no additional fees). However, at this point, the Omnicam is a somewhat closed system – meaning you will need the Dolphin Study Model module to enable STL file exporting. This is important because not all labs can directly accept Omnicam files, so you would be required to export and send the files to the lab. Like the True Definition, the scanning wand does not have sleeves but rather is disinfected after each use.

IMAGE 4: 3M TRUE DEFINITION

IMAGE 5: CEREC OMNICAM

COST OF OWNERSHIP The largest hurdle that most people need to get over when purchasing a scanner is the initial price. Most people pause, rightfully so, before spending $20,000+ on a single piece of equipment that may or may not make you money. Also, the initial cost of a scanner is not the full equation. Yearly software fees and consumables are not insignificant for most scanners. Would you be surprised if I told you that the iTero Element (MSRP of $29,999) and Trios 3 Color (MSRP of $39,000) cost almost the same price over

five years when all else is equal? (Figure 1) Most people do not take the yearly fees and consumable cost per scan into account when deciding on what scanner to purchase.

–––––––––––––––––– It is my opinion that when you integrate a scanner into your practice, you should find as many reasons to use it as possible. The obvious reason is aligner therapy. Aligners fabricated from scans (versus PVS impressions) fit better and result in a better patient experience, in addition to the faster turnaround time. ––––––––––––––––––

Initial Cost

Support & Scan Fees

Total 5 Year Cost (+ consumables for 500/yr)

3M True Def B&W

16,000

2,400/yr

28,000 + 0 = 28,000

3M True Def B&W w/ INV

16,000

3,500/yr

33,500 + 0 = 33,500

Trios 3 Mono

24,900

3,000/yr*

36,500 + 1,000 = 37,900

Cerec Omnicam

29,999

2,388/yr

41,939 + 0 = 41,939

iTero Element

29,999

4,320/yr*

47,279 + 6,250 = 53,529

Trios 3 Color

39,200

3,000/yr*

51,000 + 1,000 = 52,200

CS3600

39,999

0/yr

39,999 + 6,250 = 46,249

FIGURE 1 35

It’s just BUSINESS

Q1 • 2017 | TheProOrtho.com 35


OFFICE LOGISTICS UTILIZING SCANNERS It is my opinion that when you integrate a scanner into your practice, you should find as many reasons to use it as possible. The obvious reason is aligner therapy. Aligners fabricated from scans (versus PVS impressions) fit better and result in a better patient experience, in addition to the faster turnaround time. My practice has been impression free since mid-2013. The road to get there was not without bumps, but we have developed the systems to support our plaster free practice. The ability to take a scan and send it to a lab that is experienced with indirect banding has been an amazing paradigm shift for us. For most appliances, we scan and allow the lab to fit bands on the models. The appliance is delivered two weeks later. Debands are a different animal because we do not want to wait an extended period of time between removing the appliance and retainer delivery. To prevent this, we deband the patient and include a scan with our final records. The retainers are turned around quickly enough for us to deliver within five days. While it does cost more for appliances (due to the model printing and indirect banding), the patient experience is significantly improved. There are many labs that have experience with indirect banding (Specialty Appliances, NEO

Lab, AOA, and Dynaflex are among the largest). A common question that arises is: do labs fabricate soldered appliances directly on the printed models? Yes and no. Most labs use traditional soldering methods, which require that the model be duplicated in stone for appliance fabrication. However, laser welding (which is significantly smaller and stronger than soldering) can be performed directly on the printed models. Very few labs use laser welding at this point in time because of the extra cost and expertise involved, but it is an emerging trend. DIGITAL RETENTION To me, the single greatest use of a scanner is the ability to virtually eliminate lost retainer appointments for those who have been wearing their retainers. By combining the digital model and 3D printing, we have the ability to fabricate as many retainers as we want on a single printed model. As long as the patient has been wearing their retainers, a new Essix can be easily fabricated and mailed out; thereby eliminating a trip for them to the office and opening up a chair for a more profitable procedure. According to my math, it costs approximately $30 to fabricate a retainer from a printed model off of a previously scanned patient versus approximately $100 to fabricate a retainer

Printed Models Chair Time* (impression)

$0

$75 (15 min)

Model Materials

$24

$.50

Pour Up (staff**/stone)

$0

$2

Retainer fab (staff**)

$2.50

$2.50

Retainer fab (plastic)

$4

$4

Chair Time* (delivery)

$0

$25 (5 min)

Total Cost

$30.50

* Assuming $300/hr/chair of production ** $15/hr employee

FIGURE 2 36

Stone Models

It’s just BUSINESS

$109

from an in-office alginate impression (Figure 2).

–––––––––––––––––– It is my opinion that when you integrate a scanner into your practice, you should find as many reasons to use it as possible. –––––––––––––––––– IS IT TIME TO BUY? Many people believe that the cost of scanners will be coming down significantly over the next few years. I am not in that camp. I don’t believe that any scanner company wants a race to the bottom with regard to fees. Align raised the price of the Element shortly after it was released. While it is true that technology tends to become more affordable over time (look at TVs – we all remember when a flat screen HD TV was several thousand dollars, and now they are basically disposable), but I don’t see the trend for scanners to come down in price in the near future. Those that wait for the price to come down are going to find themselves behind the times and struggling to keep up. I do not believe that a scanner will MAKE you money. They are a significant purchase that ends up costing much more than the initial price due to software fees and consumables; however, most of us are willing to spend more money on pre-adjusted or self-ligating brackets, NiTi/TMA wires, and digital radiography because they make the patient experience better and your staff happier. In the long run, this is what will make you money. A happy staff and an office that does not take impressions will help you build a brand that attracts patients and differentiates yourself from the practices down the street that are waiting for the price to come down.


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BUSINESS & PRACTICE DEVELOPMENT

Increasing Access to Care: SmileDirectClub’s Growing Role in Outpatient Orthodontics By Dr. Robert Sims As orthodontists, the goal has always been to help people align their smiles. While crooked or gapped teeth can cause issues with oral health, for many people the impact is even bigger, creating a barrier for advancement and opportunity. At the end of the day, the more smiles we can transform, the more people we can help. According to the latest data from the American Association of Orthodontists, one-third of American adults are unhappy with their smiles. Fifty-six million Americans have mild to moderate malocclusion, but just 2.8 million are receiving inpatient orthodontic care. That’s only five percent of those who could be treated. What are the barriers stopping people from transforming their smiles? Cost, of course, is at the top of the list, with traditional braces and inpatient invisible aligner treatment ranging anywhere from $3,000 to $8,000 on average.

38

Teledentistry has been around since the 1990s in various forms. More recently, it has offered a way to expand access to care without removing the professional oversight required for moving teeth. SmileDirectClub is a relatively new entrant among companies that are leveraging the lower cost of 3D printing, technology and an understanding of navigating regulated industries while working with medical professionals to expand access without in-office visits. The end result is the ability to work on behalf of a network of orthodontists to approve, create treatment plans, monitor cases and deliver invisible aligners directly to their customers remotely. This ability is cutting the cost of traditional treatments for mild or moderate malocclusion by up to 70 percent. “Getting braces was never really an option for me as a kid,” explained Tiffany E., a customer currently using SmileDirectClub’s outpatient model to realign her smile. “Growing up, we didn’t have dental insurance. My parents couldn’t drop $8,000 on each kid. And even as an adult, it still isn’t an option. SmileDirectClub made something that I’d have been looking at as an option eight to ten years down

It’s just BUSINESS

the road—provided my kids don’t end up needing braces—possible today.”

–––––––––––––––––– As SmileDirectClub has grown over the past couple of years, more orthodontists are beginning to acknowledge not only the feasibility but also the benefits of outpatient orthodontics when it comes to increasing access to care. –––––––––––––––––– Cost wasn’t the only obstacle for Tiffany to be able to undergo orthodontic treatment. “I don’t drive, so when I have to go to an appointment, I have to schedule it around my husband’s busy schedule. Now, I don’t have to worry about that.” With SmileDirectClub’s remote treatment model, customers don’t have to make time for in-office visits, adding a level of convenience previously unseen in orthodontics.


BUSINESS & PRACTICE DEVELOPMENT

“The shorter treatment plan has been a huge benefit for me, too,” Tiffany said, referencing the speed of SmileDirectClub’s invisible aligners versus some of the other brands available. “I didn’t have the time to invest in two or more years of office visits. But with SmileDirectClub, I blinked, and I’m over halfway done now. It’s huge.” In Tiffany’s case, she had never had traditional braces or in-office invisible aligners, but there are thousands—if not millions—of adults who had braces as children or teenagers and are now experiencing dental relapse from lost or broken retainers. Once again, the cost of in-office treatment is preventing many of these people from getting their smiles back in line. Take Lauren D. for example, a customer who is currently just a few sets of invisible aligners short of completing her treatment. “I had braces as a young adult,” she explained. “My permanent retainer broke, and ever since that happened,

my teeth have gotten progressively worse. I’d gone to several consultations over the past seven to ten years, but I had braces before. I didn’t want to spend $8,000 correcting something that was relatively minor.” But then Lauren heard about SmileDirectClub. “I saw an ad on Instagram and started looking into it. As a registered nurse, I’ve seen telehealth become very successful. So why wouldn’t this be? I did a lot of research and decided to go forward with it. The process has been so easy. I recommend it to everyone.” I was one of the early prescribing orthodontists in the SmileDirectClub network. In the beginning, the company faced pushback from industry professionals and dental boards who weren’t certain if teledentistry could be applied to moving teeth. As SmileDirectClub has grown over the past couple of years, more orthodontists are beginning to acknowledge not only the feasibility but also the benefits of outpatient

orthodontics when it comes to increasing access to care. Since I started working with the company a few years ago, thousands of people who may never have considered orthodontic treatment an option have transformed their smiles safely and effectively. Of course, there are and will continue to be cases that can only be corrected with inpatient orthodontic treatment. Earlier this year, Invisalign invested in SmileDirectClub with the understanding that they serve different populations and handle different types of cases. SmileDirectClub refers out roughly 30 percent of its prospects for in-office treatment to Invisalign. But for the rest of its customers, by increasing access to care for these people, SmileDirectClub is helping me and other orthodontists do what we want to do all along: make more people smile.

Q1 • 2017 | TheProOrtho.com 39


MARKETING, SOCIAL MEDIA & EVENTS

Are Orthodontists a Commodity? By Angela Weber Do consumers think orthodontic services are a commodity like the milk they buy at grocery stores? Most orthodontists would insist that their practices are certainly not interchangeable with other ones, but OrthoSynetics’ research shows that consumers think otherwise. OrthoSynetics recently commissioned a study to evaluate public opinion associated with orthodontists and orthodontic treatment. One of the findings showed that the number one thing people consider when selecting an orthodontist is “affordability of treatment” (60%), and the next two cited considerations were “convenient location” (49%) and “board-certified orthodontist” (48%).

–––––––––––––––––– Think of your brand as the emotional experience the public has when interacting with your business. –––––––––––––––––– While orthodontists looking to differentiate themselves from dentists will find the “board-certified orthodontist” consideration reassuring, it also implies that consumers believe that as long as an orthodontist has had requisite training, that’s good enough for them. And the top two considerations of price and convenience reveal even more how consumers see orthodontic services as a commodity. After all, if you ask someone in a checkout line why they bought a

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certain jug of milk, they might say that it was the cheapest and easiest to grab. But take heart. Even virtually identical products on store shelves are able to stake out their own corners in consumers’ minds. Some people will buy the lowprice store-brand milk, others will buy milk marketed under a large national brand like Borden, and still others might choose a local, organic provider. The difference between these products is they are, um, differentiated. Orthodontists need to differentiate too. YOU NEED A BRAND AND NOT JUST A LOGO Think of your brand as the emotional experience the public has when interacting with your business. Your logo is the graphical representation of your brand, but your brand has a wider scope than just one image, and your brand is the biggest defense you have against your competition. Creating a consistent brand allows consumers to get to know you and what you stand for. You want your brand to be familiar and ring true to who you are. Too often I’ve seen practices mimic each other’s brand. They borrow catchphrases, slogans, and stock photos. Your brand should never be interchangeable with another’s. CONSIDER THESE POINTS WHEN DEVELOPING YOUR BRAND MESSAGING: • Why should patients/parents choose you over any other competitor? • What compliments do you routinely hear from patients/parents? • Why should patients/parents trust you? • Why did you become an orthodontist?

It’s just BUSINESS


MARKETING, SOCIAL MEDIA & EVENTS INJECT YOUR MARKETING WITH FEELING AND PURPOSE Patients will pay for quality orthodontic services, but an emotional connection with patients and parents is key. Consumers will buy with emotion and justify the price. Orthodontic ads that focus on smiling, happy patients and positivity, can increase engagement and translate to positive feelings about your brand. All the same, smiling, happy patients aren’t quite enough because all practices use this imagery. Originality is vital. Craft a message around what’s important to you. Marketing with feeling and purpose forges a connection between your practice and patients. It’s also an opportunity to unite your team with a common goal. You’ll notice that not only will your patients feel better about you but so will your practice team. USE PATIENT EXPERIENCE AS DIFFERENTIATION Want to separate yourself from everyone else? Be good to your patients— really, really good. Taking great care of patients creates loyal and raving fans. That’s something that’s hard for the competition to duplicate. It sounds easy, but it’s not. It takes a disciplined practice owner and team to pull this off. A patient’s experience with you and your practice is as important as your actual treatment outcomes. It’s not enough to say you have “fun and friendly atmosphere” (which is a standard communication point in orthodontic advertising). And if you are saying that, answer for yourself, What does “fun” mean? What does “friendly” mean? Figure it out and put those concepts into action. It’s important to walk the talk each and every day and do what you say. It’s time to get your practice in sync with your messaging. SPELL IT OUT Don’t leave it to the consumer to figure out what the differences are between your practice and your competitors’. Once you’ve developed your brand story and

differentiation strategy, you need to beat that drum every day. Consistency is key. Social media, blog posts and marketing pieces should continually reinforce why are you different and why consumers should choose you.

–––––––––––––––––– Want to separate yourself from everyone else? Be good to your patients—really, really good. Taking great care of patients creates loyal and raving fans. That’s something that’s hard for the competition to duplicate. It sounds easy, but it’s not. –––––––––––––––––– As a test, do a quick competitive review. Visit the social media pages and websites of your competitors. You’ll probably notice how shockingly similar they all are. How do your materials compare? Could you swap out your website welcome page with theirs and not notice much of a difference? If so...if you can’t tell the difference, well then neither will consumers. It’s up to you to educate consumers why they should choose an orthodontist over a dentist and why should they choose your practice over one down the street. Here’s the bottom line message. If you want more patients, you need to create a marketing program that clearly communicates why your practice is the best choice for them. If not, they will have no ability to understand why your fun and friendly environment is different than anyone else’s.

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BUSINESS & PRACTICE DEVELOPMENT

CZZh DN Orthodontics 42

It’s just BUSINESS


BUSINESS & PRACTICE DEVELOPMENT

This quarter ProOrtho sat down with two of the most well-known, successful and respected orthodontists in the world. Dr. Jack Devereaux and Dr. Phuong Nguyen have multiple practices in Louisiana and their business a direct reflection of these two go-getters. Orthodontists would do well to listen and learn from these seasoned veterans who stick with what works while changing when the changing landscape demands flexibility.

HOW DID YOU GUYS MEET? At the time of Hurricane Katrina, Dr. Jack Devereux had locations in Slidell, Harvey, and Picayune. Because many providers did not return to the city, Dr. Devereux opened his doors for four days after the storm and welcomed all patients for no charge. This caused the practice to grow very rapidly. The storm caused severe damage to the roadways, so the commute between the locations was taking 2-3 hours. A sales rep knew he was in need of help and made the introduction to Dr. Phuong Nguyen. After Dr. Nguyen had graduated from his Orthodontics residency, he spoke with Dr. Devereux about the possibility of becoming an associate, but Dr. Nguyen’s heart was set on teaching. Hurricane Katrina caused the dental school to be shut down, and the classes were moved to Baton Rouge. Because of the school’s closure, Dr. Nguyen joined as an associate with the intentions of partnering with Dr. Devereux. THIS ASSOCIATESHIP FORMED A PERFECT STORM THAT TURNED INTO AN INCREDIBLE PARTNERSHIP. Dr. Devereux decided that after working with Dr. Nguyen that he would rather create a partnership with Dr. Nguyen then compete with him. In return, Dr. Nguyen committed to Dr. Devereux that he would grow the practice and make his half more than the practice as a whole. However, instead, they made a commitment that they would make this


BUSINESS & PRACTICE DEVELOPMENT practice grow together with the intentions of providing the best quality care at an affordable cost throughout the Gulf Coast. AS THE PARTNERSHIP BEGAN, IT WAS OBVIOUS THAT IT WOULD BE SUCCESSFUL FOR ALL PARTIES INVOLVED. The doctors came into the partnership respecting each other’s core competencies. They never questioned one another’s skills or micromanaged each other. Part of what made the transition to partnership so easy was their ability to unite behind a single clinical philosophy.

–––––––––––––––––– My vision for the future in ortho is that advertising is going to go back to where it was before direct to consumer advertising but brought to another level because social media is direct to consumer advertising on steroids. –––––––––––––––––– As the structure has changed over the years, they have always stepped back to redefine their roles so they can continue to grow the practice. The have held the same goals; always put the patients and employees first and respect each other’s differences and commonalities. AFTER LEARNING ABOUT THE FOUNDATION OF THEIR PARTNERSHIP, WE SAT DOWN WITH DRS. DEVEREUX AND NGUYEN TO LEARN MORE. Pro Ortho: Dr. Devereux, you have been

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around a long time and always come up smelling like roses, and everyone loves you. How do you manage that? Dr. Jack Devereux: Be honest, treat patients and staff the way I would like to be treated and do the right thing. Even if it might end up costing me more money, I still do the right thing. It ends up benefiting everyone from time and Dr. Nguyen, the employees and the patients. It sounds cliche, but I’ve never worried about who gets the credit for our growth as long as we continue to focus on our main goals we all benefit.

was before direct to consumer advertising but brought to another level because social media is direct to consumer advertising on steroids. When I first started, you depended on word of mouth or doctor referrals. Now with social media, your reputation is almost more important than it was back then because it can spread so fast. People trust their social media connections more than advertising. There will always be a place for affordable care because social media will weed out the corporate practices who perform a less quality affordable care.

Pro Ortho: Dr. Devereux, you were one of the first to advertise direct to consumer and do big volume. I’m sure you got grief for that back in the day. What’s changed since you first stated and where do you think ortho is headed? Dr. Devereux: I got tremendous grief from the established ortho community and the academic community for doing direct to consumer advertising. There were questions about my quality, morals, and ethics. At the time my favorite saying was if a lady wears a red dress it does not make her a lady of poor morals. My guiding and continual mission has been to provide the highest quality affordable care to the greatest number of patients possible and direct to consumer advertising was a way to increase the number of people I was able to help. Having a great product or service that no one knows about is not a benefit to many people. I think history has proven me correct and now the vast majority of orthodontists are doing some form of direct to consumer advertising. I think that what differentiates me from most is the quality and detail of our systems and processes which allow us to fulfill our mission of providing the best quality care at an affordable price because without good systems a typical ortho practice would do poor quality at a high volume. My vision for the future in ortho is that advertising is going to go back to where it

Pro Ortho: Dr. Nguyen, you two work together but focus on different aspects of your business right? Tell us about that. Dr. Nguyen: We focus on the things that we are stronger at knowing we are complimentary in our skill sets. While our mindsets are congruent, our skill sets are different which makes us complementary to each other. Dr. Devereux taught me how to be a visionary and a leader by looking past the procedural details and focusing on the big picture. I can still take a look at the procedural systems details when needed because I know Dr. Devereux is still going to focusing on the visionary aspects.

It’s just BUSINESS

–––––––––––––––––– When I was a patient having braces changed my smile and my life. I wanted to do the same thing for other people, changing their smile and in turn making their lives better. ––––––––––––––––––


BUSINESS & PRACTICE DEVELOPMENT Pro Ortho: Dr. Nguyen, why did you decide to become an orthodontist? Dr. Nguyen: When I was a patient having braces changed my smile and my life. I wanted to do the same thing for other people, changing their smile and in turn making their lives better.

–––––––––––––––––– Because many providers did not return to the city, Dr. Devereux opened his doors four days after the storm and welcomed all patients for no charge. This caused the practice to grow very rapidly. –––––––––––––––––– Pro Ortho: Dr. Devereux, same question. Dr. Devereux: My first wish in dentistry was to become an oral surgeon and the more I worked in the industry I realized the less I liked it. Then my analytical thinking lead me to becoming a periodontist in the early 1980. At the time the the baby boomers were starting to age and thought I could be busy for the rest of my life. At the general dentistry practice where I started my career, I was working as a general dentist but was also performing orthodontic procedures. I enjoyed it but I didn’t really know what I was doing. My wife at the time, who was also a general dentist, pointed out that my personality type would never be happy in perio or general dentistry. She made me realize I needed to be around young healthy people who wanted to look better. When I started to think about it I remember myself before

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BUSINESS & PRACTICE DEVELOPMENT

I had braces I was a shy goofy kid with crooked front teeth. After my smile was corrected I was an outgoing kid who ended up being the student council president. Pro Ortho: Dr. Nguyen, your wife is a Pediatric Dentist right? Do you guys work together? Tell us about your views on ortho pedo in the future. Dr. Nguyen: Yes, she is. When she’s mad at me at home our starts go down, when she’s happy our starts go up. Happy wife, happy production. I think there are different models that will work, ortho and pedo is a good model but it is not the only model. I wouldn’t go out and find a pedo dentist just to partner up with them because I have seen models that do well without a pedo.

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It’s just BUSINESS


BUSINESS & PRACTICE DEVELOPMENT

Q1 • 2017 | TheProOrtho.com 47


BUSINESS & PRACTICE DEVELOPMENT

The MKS Forum 2016

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Iw wanted anttte an ted ed tto o ccongratulate ongr on grat gr atul at tul ulat lat ate te y you ou o on np putting utti ut tti ting ng g ttogether og get ethe th herr he an amazing an ama mazi zing g conference! confere renc n e! As a n new ew busin ew business nes esss ownerr I gain gained ined ed so om much uch valuable val alua uabl ble e knowledge kno owled wledge ge and and it was was so so refres refreshing eshi hing g ccompared ompa pare red d to o other th her e con conferences o fe f re encess I'v I've ve bee been een n to. - M to. Matt attt A at Ahrens hren hr enss

“Amazing!” “Inspiring!” 48

It’s just BUSINESS

530 Doctors 530 Doctors & Their Their Teams Teams


BUSINESS & PRACTICE DEVELOPMENT

a massive success I learned lea earn r ed rn d tthere he h ere r a are re o other ther ther th er w wierdos iie erd rdos dos os llike ik ke m me e o out utt tthere, he h ere re,, liike like ke Fag Fagala ag gal ala aa and nd Sch Schirk hir irk that tha at lik like ke to o rread ead b ead books ook oo ks tto ks o iimmpr ve their prov prove the heir i llives!! ives es!! W We e have hav ve some some e AMAZING AMAZI MAZ NG G young you oung ng g peop people ople le that tha hatt a are re Doe Doers oers rs in nO Ortho. rtho rt ho. o. K Keep eep ee p the he iinspiranspi ns pira r tion ccoming. tion oming. g. IIll l see ll ee y you ou a all ll nex next xt y year! ear! - B ear Britt ritt ri t R Reagin ea agi gin n

MK M MKS KS was was a beautiful beaut utif tif iful ul e ul event ve entt a and nd d iitt w was as a an na amazing mazi zing ing g week weekend. eken end. I rea really eally ya appreciate ppre pp reciat ate e the he eo opportunity ppo tunity ppor ty to b be e in inspired/learn/network nsp spir i ed ed/l /lea earn r /net etwo worrk and I w wanted ante an ted d to tha thank hank nk y you ou for everything for every ryth thin ing g you you do do for the the e community. community ty. y. T The he iimm-pacctt you pa pact you have hav ve can'tt be measured. measu easure ed. d -E Evan van T Tran ra an

“Refreshing!”

www.TheMKSForum.com www.T .TheMKSForum.com

“Impactful!” Q1 • 2017 | TheProOrtho.com 49


CLINICAL CORNER

O]b%OWb\

THE ATTACHMENT: The Clear Path to Molar Zen By Dr.Jonathan Nicozisis

–––––––––––––––––––––––––––––––––––––––––––––––––––––––––– ‘At the moment of surrender, a vision over visibility…’ – Paul Hewson –––––––––––––––––––––––––––––––––––––––––––––––––––––––––– Align Technology’s commitment to eliminating brackets from the landscape of the orthodontic discipline is imitable and unparalleled. Likewise, the private practitioner’s yearning for constant improvement is unwavering. These two forces can be both complimentary and antagonistic simultaneously. Much like the Chinese philosophy of Yin and Yang, their interaction is thought to maintain the harmony of the [orthodontic] universe and to influence everything [each other] within it. The net result often is the advancement of the orthodontic discipline, like a rising tide lifting all boats. The generational improvement known as G6 was created by Align to address molar anchorage and molar protraction in bicuspid extraction cases. Due to the mass customization and scalability of the appliance, as expected, certain limitations and parameters must be imposed to limit variabilities that would otherwise make discerning what goes wrong a monumental task. It is the application of the scientific method at its finest. Currently, G6 parameters limit mesial molar movement to 2mm or less. If certain thresholds are not met, G6 will not be applied and cannot be customized as it is an ‘all or none’ solution. The private practitioner is often faced with mesial molar movement greater then 2mm. Since the G6 solution cannot be applied, the private practitioner must be the yin to Align’s yang and push the limits applying sound principles of tooth

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movement taken for granted everyday with fixed appliances.

FIG 1 The unmet clinical need is when moving molars mesially greater than 2mm, we must design our appliance force system to render a center of rotation within the clinical crown to affect mesial root tip. Furthermore, our clinical experience has proven that control of the vertical dimension is as important as the sagittal movements. When using fixed appliances and closing loop arch wires, we routinely gable bend in the extraction site area, tip the mesial of the bracket slightly apical to get the extra mesial root tip when the wire is inserted and finally use a hollow-chop plier to swipe curve in the closing loop arch wire to prevent dumping or bowing of the arch during space closure. As such, a twin attachment (Fig 1) should be employed on molars to impart of the forces necessary for the mesial root tip. Clin Check Pro may be utilized efficiently to ‘dial-in’ the desired amount of mesial root tip. This twin attachment

It’s just BUSINESS

best mimics the arch wire binding in the slot in that when a molar moves mesially it tips, the bracket slot binds the wire, uprights the roots and repeats. Hence, the molar sort of ratchets along the wire. The Yin/Yang twin attachment on molars best mimics the wire/bracket binding forces that uprights the roots mesially. Finally, the clinicheck must be designed to mimic using the hollow-chop plier to swipe curve in the wire to manage the vertical dimension. Accordingly the second molars need to be intruded 2-3mm each followed by the first molars 1.5-2.5mm each and the second bicuspids 1-2mm each rendering a posterior open bite in the final stage of the clincheck with freeway space between the opposing occlusal surfaces. (Fig 2.)

FIG 2 The final image is no different than the curve and reverse curve placed in the upper and lower arch wires rendering a perfect final occlusion. Yet, if untied and placed on the bracket table, their form and appearance would look excessive to what we see clinically in a similar fashion to the view of the final stage in clincheck.


CLINICAL CORNER At the moment when all hope is lost and you have surrendered, U2 can have clairvoyance and the vision to translate the action of fixed appliances to lexicon of aligner therapy rendering tooth movements previously thought of as impossible as common place. The mindset that allowed our discipline to transition from banded to direct bonded appliances, must now continue to ‘attach’ its beliefs to the fundamental principles of physiology of tooth movement regardless of the appliance system chosen. As Confucius once said, we may learn wisdom by three methods: First, by reflection, which is noblest; Second, by imitation, which is easiest; and third by experience, which is the bitterest. Instructions for Communication: Twin attachments on the molars. Mesial half: 2mm wide horizontal rectangular beveled occlusal 1.25mm thick and tapering into the crown without a ledge, Distal half: 2mm wide horizontal rectangular beveled gingival 1.25mm thick and tapering into the crown without a ledge.

12 MONTH PROGRESS NOTE BUCCAL OPEN BITE

REFINEMENT INITIAL STAGE

REFINEMENT FINAL STAGE: NOTE CURVE PLACED IN THE UPPER WIRE WITH POSTERIOR FREEWAY SPACE

INTITIAL Superimposition of first CC: Note the MRT dialed into the upper 6,7’s. The mistake made by bitter experience is that they are moved forward on the same plane as the occlusal plane. This led to the ‘bowing’ effect. No different than making a closing loop arch wire and never wiping a curve in it with a hollow chop plier.

23 MONTHS OF TREATMENT: REFINEMENT 2 Q1 • 2017 | TheProOrtho.com 51


CLINICAL CORNER

INITIAL

11 MONTHS IN CR SCAN

11 MONTHS OUTCR SCAN INITAL CEPH

START WITH MARA

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It’s just BUSINESS

11 MONTHS MARA REMOVAL SCAN


CLINICAL CORNER

INITAL 11 MONTHS

13 OUT YIN-YANG USED TO MOVE LOWER MOLARS

11 FINAL

Q1 • 2017 | TheProOrtho.com 53


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BANDS TO BRACKETS & ANALOG TO DIGITAL By Dr. Ben Burris As a long time Invisalign hater I can sympathize with the orthodontists out there who are constantly rationalizing their refusal to give patients what they want by telling me things like: “Braces are the gold standard; I can’t look patients in the eye and tell them Invisalign is an equivalent alternative.” “Patients, especially teens, won’t wear their aligners enough and so we put braces on them.” “My patients want braces and colors.” “My patients agree with me, and like that, I refuse to compromise when it comes to their treatment.” “You can’t get proper torque, proper root parallelism or well-aligned 7s with Invisalign.”

I did and said the same thing for a long time. I kept telling patients Invisalign was not good treatment and putting those who asked for Invisalign into braces… or trying to anyway. After years of seeing patients walk out the door rather than get braces, I finally wised up (not to mention all those I never even saw because they didn’t come to me). I would challenge you to track the patients who don’t start with you and follow up with a survey monkey questionnaire on why they didn’t accept your treatment recommendation. If you do this with an open mind, you’ll be surprised when it comes to Invisalign treatment among other things – otherwise, confirmation bias will blind you to reality. Self-assessment is hard, after all. The problem with the doctor’s

objections listed above is that they are based on assumptions about what patients want that are just plain wrong. The main assumption that blinds most orthodontists is that patients want perfection – that they want OUR definition of perfection – and that patients are willing to do whatever it takes to get there. This assumption, though almost universally accepted by orthodontists, is wrong for a number of reasons: There is no such thing as a perfect case. Nope. I know you think there is but send me photos and I’ll post the case you think is perfect and let your peers rip it to shreds. There is too much asymmetry in the average human and too many variables to achieve “perfection” or “ideal” so seeking either is foolhardy. The best

---------------------Treatment doesn’t happen in a vacuum. Our job is to get the best result possible within the constraints our patient/customer sets for us. ----------------------56

It’s just BUSINESS


BUSINESS & PRACTICE DEVELOPMENT description I’ve ever heard of treating a case is from my good friend Dr. Marlin Grimes. He told me that treating a case is like painting a landscape. You start out with broad strokes of sky and earth and then work down to the fine details of trees and animals and grass and birds, but at some point, you’ll have to decide it’s done. Not perfect, but done to the best of your ability. The alternative is to never finish anything. A canvas won’t complain but patients will and do. Treatment doesn’t happen in a vacuum. Our job is to get the best result possible within the constraints our patient/ customer sets for us. What kind of constraints? Well, the first one is money. If a potential patient refuses to pay, generally you refuse to treat. The second constraint is time. If a patient refuses to show up then, you can’t get a good result. Compliance is the third constraint. If patients don’t brush or constantly break things or don’t wear elastics, then you can’t get a good result. If the patient refuses jaw surgery or extractions, then you are limited in what you can do. Finally, there is convenience/expectations/satisfaction. If a patient is tired of treatment or thinks their smile is “good enough” the wise orthodontist removes their appliances… but many fight the customer and tell them what they want. You can only do what the patient allows you to do. That is how it should be since it’s their head and we work for them as hired help. Better is better. There are different levels of care that patients can choose from, and if they choose a lower level of service/ treatment, then that is that. This isn’t North Korea after all.

---------------------------I GUARANTEE you that if you give patients a choice between brackets and bands, they will take brackets every time yet we orthodontists persist in our refusal to embrace new, proven technology and continue to point out the few exceptions where bands are necessary. ---------------------------I know that almost none of you have read the book, The Innovator’s Dilemma, and I want to encourage you, yet again, to do so immediately. If you do, you’ll see clearly how and why I make assertions about the product we orthodontists deliver routinely exceeding customer needs, and you’ll learn why that matters. In the context of this book you’ll see that not only is the quality of Invisalign treatment good enough, it routinely exceeds the expectations of our customers as well. How do I know this? Simple – SmileDirectClub stipulates to the fact that they can’t do what a traditional orthodontist does with Invisalign or braces yet SmileDirectClub customers are very satisfied with what they are getting in terms of results and value! What does that tell us? A great deal if you take the time

to understand the market. What you want doesn’t matter. What you think customers need matters little. What the customer wants to do with their body matters. What the customer is willing to do in terms of time, money and effort dictates treatment modality and clinical result in most cases. Ok so let’s try to relate this to orthodontic history because I know “it’s different here.” Think about when we orthodontists first started using bonded brackets instead of banding every tooth. I wasn’t around, but my understanding from those who were is that there were two camps. Those who embraced the new technology despite the setbacks of broken brackets and the limitations of self-curing adhesive vs. those who rejected the new technology and coined the term “stick-on brackets” as a derogatory way of putting them down and justifying their use of bands. Though arguably inferior when they first came out, bracket technology continued to improve, and adhesives improved and eventually bonded brackets became the gold standard. Kind of. A large percentage of orthodontists still subject their patients to unnecessary pain with separators and use bands despite the fact that brackets are proven and much better for patients (often while griping about overhangs and open margins from dentists…). They do this because they don’t want to change and learn and because they are lazy. I GUARANTEE you that if you give patients a choice between brackets and bands, they will take brackets every time yet we orthodontists persist in our refusal to embrace new, proven technology and continue to point out the few exceptions where bands are necessary.

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Well, duh, of course, you need to band a tooth that is crowned (sometimes) and band teeth to make an appliance or band a tooth when a bracket breaks more than twice but that doesn’t mean you wholesale

---------------------------Better is better. There are different levels of care that patients can choose from, and if they choose a lower level of service/treatment, then that is that. This isn’t North Korea after all. ---------------------------58

reject brackets. Our answer to these few scenarios combined with our laziness convinces us it’s ok to subject every patient to separators and bands. It’s not. Argue all you want but while you do, go ahead and have an assistant put separators in your mouth then talk to me in a couple of days. The change from bands on every tooth to brackets IS THE SAME as the transition from analog treatment to digital treatment – the same as moving from braces to Invisalign. I suspect the move to Invisalign will follow the same acceptance curve that brackets did with a few early adopters. Followed by a significant number who partially implement (a la those who put brackets on the anterior and bands on the posterior) and ending up with a

It’s just BUSINESS

landscape where the most progressive and successful practitioners fully embrace Invisalign while everyone else says it can’t be done. In this scenario, you’ll have 20% of orthodontists killing it with Invisalign while the remaining 80 percent say, “you can’t do that” and talk about how unfair the system is while refusing to change. This creates the familiar “rich get richer” scenario where those who are giving patients what they want to get more patients and more leads and more patients and more leads while others wonder how they do it. Honestly, it’s kind of comical to watch. What side of the fence are you on? Depending on your answer, the grass very well may be greener on the other side.


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It’s just BUSINESS


BUSINESS & PRACTICE DEVELOPMENT

THREE PILLARS OF THE MODERN PRACTICE, PART 2: Creating & Managing Leverage Dr. Jamie Reynolds

MODERN PRACTICE F L E X I B I L I T Y

The Business Dictionary defines “leverage” as ‘”the advantageous condition of having a relatively small amount of cost yield a relatively high level of returns.” Entrepreneur Magazine describes leverage as “the key to making what you have go much further. Just like a crowbar or a moving dolly, leverage allows you to harness the power of good positioning and the strategic application of energy to move mountains.” Orthodontists often get itchy thinking about leverage, if they even know what it is. And, to be clear, I have only recently come to truly understand this concept thanks to my exposure to very smart “real”

L E V E R A G E

business people. Leverage is a very powerful business concept absent from our traditional training (read: complete absence of business training in orthodontic residency). Here is the question: how do we apply the concept of leverage to the practice of orthodontics? I do a lot of lecturing on Insignia and self-ligation and I use a lot of Invisalign in my practice. I’ve heard the following comment often-and I know that the people over at Invisalign hear it until they’re blue in the face: “I need to get X amount of dollars upfront to cover my lab costs before the patient can start.” For Insignia, it’s usually north of $1,000, and for

S Y S T E M S

Invisalign, it’s typically $1,800 or more--because people (us people) think that they need to always cover their lab costs in order to justify starting treatment. As I will describe next, this thinking is a perpetuation of previous dogma and a blockade to the creation of leverage--and growth--in your practice. CREATING LEVERAGE So, how do you intentionally create leverage? Let’s first look at data we have collected from over 90,000 new patient exams, over 60,000 starts and over $300,000,000 in orthodontic production. Each dot on the chart illustrates the

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BUSINESS & PRACTICE DEVELOPMENT

combination of monthly payment and down payment selected by a person who financed treatment (payment in full was not included here). One of the amazing things we have witnessed when people are given the choice to pick their own terms is the wide and surprising variety they choose. If you reference the chart, someone actually picked $250 down and $740 per month. Another person selected $4,500 down and $50 per month. No one has those terms as part of the options they typically present, yet there are people who would choose them if offered. Circled in red is the average range of what most people offer with their financial terms. One thing to notice in the chart--90% of dots are outside the “normal” or “average” range. “Average” is not synonymous with “most.” So, how do you manage this new untapped leverage?

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YOU’VE ALREADY GOT THE ANSWER! The area shaded in green represents the people who chose terms most orthodontists would term favorable to them--plans with a higher down and/ or a higher monthly. What we typically do is take that money and put it in our pocket and consider it ours--even though we haven’t completed the treatment yet. We are all very willing to take money from people when we haven’t done the treatment, but we all get very itchy thinking of letting someone start treatment without covering our up front costs. What’s the solution? Rather than eliminate those people from your practice, simply take some of the money the people in the green shaded area give you and apply it to the lab bills for the people in red. Voila! Leverage created. Now, I know what many of you are thinking: “I need to cover my lab

It’s just BUSINESS

bill before allowing someone to start treatment.” This outdated idea couldn’t be more foolish, short-sighted, or expensive (to you). The only thing you’re doing by always charging everyone a $1,500 down payment to begin treatment is stunting the growth potential of your practice and preventing you from earning more business (and, therefore, more profit). The smarter philosophy would be to allow lower down payments and extended terms and charge interest where applicable to hedge your default risk (as described in a previous article). Using the philosophy described in this article is a driving reason why OrthoFi clients average over 14% growth over prior year using the service. Creating leverage, rather than creating an insurmountable down payment, is the key to making what you have go much further. Entrepreneur Magazine, as well as


BUSINESS & PRACTICE DEVELOPMENT every savvy business person, knows this already. The large Dental Support Organizations know it as well, which is exactly why they advertise based on very flexible orthodontic terms. It is time for orthodontists to utilize leverage before our restrictive terms drive more patients away from where they belong--in the hands of a highly skilled orthodontist.

MANAGING LEVERAGE Before discussing philosophies of cash flow management, it is important to emphasize that orthodontists, in general, don’t manage their cash flow well. Far too many of us practice what I like to call “lemonade stand” cash management. We sell our lemonade (pronounced “braces”,) collect money, pay bills, and smilingly shake the cash box on our way to spend what is left over. “Real” businesses understand seasonal swings, and strategically budget the amount of operating profit they spend over time. They then periodically (semi-annually rather than monthly or weekly) bonus the extra earnings into a reserve cash fund. Only when the reserve cash fund becomes large enough to cover

several months’ expenses do they sweep the leftover cash into the profit bucket. This concept is especially key in a growing business, as expenses can outpace intake during periods of rapid growth and cash reserves are necessary to make rapid growth manageable. FIRST THINGS FIRST It is important to assess your current cash flow situation. Regardless of how smart you are with cash flow, if you’re shifting from a starting point of requiring as high as $1,500 down payment from every patient to allowing flexible options, your cash flow will temporarily tighten up… but the reward for that flexibility will pay significant dividends. Growth will translate to much more revenue and profit in the long run, but you need to consider your short-term cash reserves before you implement these suggestions and be sure to build up extra cash for the first few months of growth-related cash depletion. You may not want to go to this length, but many businesses with high margins like ours use short-term lines of credit to infuse cash to fuel growth. It’s worth considering. I used to think that accessing a line of credit would be a cash management failure, but I now realize that it is smart business when used to fuel rapid growth. GO WITH THE FLOW…BUT WHICH FLOW? Ideally, all clients would pay in full, thereby eliminating the need for the office to finance receivables. The orthodontist would only need to

manage their savings (as discussed above) to allow the business to cover expenses in the leaner months. However, I am creating the need to manage cash flow. There are two philosophical routes to consider when structuring your financing to allow appropriate cash flow while simultaneously creating leverage: transactional cash flow management and aggregate cash flow management. TRANSACTIONAL CASH FLOW means evaluating every single financial transaction in a vacuum and determining the cash flow requirements for the office based on that transaction. For example, if the patient wants Invisalign, then you would need to collect, at minimum, the lab fee upfront to avoid being cash flow negative on that particular transaction. This is the most common modality for cash flow management in orthodontics. Although transactional management is much simpler, it is clear from the data that transactional management is the single biggest impediment to growth in orthodontics today. AGGREGATE CASH FLOW is the strategy recommended by OrthoFi, as it allows you to intelligently create leverage in your business while setting a healthy and consistent cash flow. You are able to allow flexibility to those that need it – and who would not start treatment without it – and still offer fair and enticing terms to those who could afford to pay more upfront. It does not cover each individual transaction, but rather the blended

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BUSINESS & PRACTICE DEVELOPMENT

impact of all total transactions. So, rather than managing each transaction individually, you monitor Key Performance Indicators (KPIs) that give you the state of your aggregate cash flow situation, and manage your cash accordingly. HOW DO YOU ENSURE A HEALTHY AGGREGATE BALANCE? OPEN CHOICE… As noted, you can see that there is an ocean of dots extending far outside the typical average plans offered around the country. Yes, some are lower down and monthly selections, but a significant number are well higher on both ends, meaning positive cash flow. Let’s start with the down payment. Most offices offer a discount for pay in full (PIF) to entice at least 20% to pay this way, then a 15-20% down with payments for those who can’t. It doesn’t have to be a binary choice of either pay-in-full or lower down and

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monthlies. Very few practices ever get 75% or 50% down because, for the most part, there’s no incentive for a patient to do that. Why not create tiered down payment incentives, with scaling higher down payments?For example, if you offer 5% PIF discount, adding 3% and 2% incentives for 75% and 50% down respectively is proven to be very effective in stimulating more patients to pick higher down options. So across over 130 OrthoFi practices, 22% of cases pay in full, and the average down payment on the rest is $834, even though the vast majority of patients had the choice to put as little as $0 down. When all these choices are blended together, the average initial payment per case is $1,354—plenty of cash flow to run a growing practice. As for monthlies, the key is to not only offer extended options, but also financially incentivize patients to pick shorter plans. Most practices don’t

It’s just BUSINESS

charge interest on payment terms, even if they extend a few months past treatment. If you simply extend plans by adding an extended 0% option to your menu, you will most likely hurt your cash flow because there is no reason for someone not to pick that option – no disincentive for extended terms. Instead, by adding a modest amount of interest to extended financing plans, you guide those patients that can afford it to shorter plans. So again, some patients choose up to 36 months if they need to, but the average plan length over 60,000 starts is 21 months, with an average monthly payment just under $200. Probably not far off from what you’re doing now… The combination of these two tactics yields a much wider scatter of plan choices both on the high and low end to create an aggregate cash flow that is sustainable, while allowing flexibility to those that need it.


BUSINESS & PRACTICE DEVELOPMENT IS IT WORKING YET? Adopting an aggregate cash flow model seems like a leap of faith – a bet of sorts that all the ‘dots’ will come together and collectively balance out. But the truth is that to work in aggregate, you need to have solid metrics to know that it’s happening, to be able to adjust where needed when you’re off the mark. That’s why it is critical to monitor select Key Performance Indicators (KPIs) throughout the month or year to track cash flow. Here are the two critical metrics we look at:

SAME DAY CASH (SDC): the combination of the money you receive each day from pay-in-full (PIF) patients and down payments (DPs). So, SDC = (PIF + DP)/Total Patient Responsibility Production. Patient Responsibility Production is Total Production minus Insurance Production. As suggested by some consultants, approximately 20% of patients should pay in full. Of the remaining 80% of receivables, approximately 17% should be collected as a down payment (17% of 80% is 14%). So, if you add 20% pay-in-fulls to the 14% coming from down payments, your SDC should equal approximately 34% of your total

patient receivables. This does not mean that every single patient that starts treatment will put 17% down. It means that the average of ALL patients should yield a 15-20% down average and a 34% total SDC, which equates to an average initial payment amount of $1,345. With that, you should have sufficient cash flow to pay your bills, with the remainder coming in annuity payments over the coming months (if your receivables are properly managed – an entirely different topic). Once you are able to monitor this powerful metric, you can now properly manage in aggregate. So when you have a month with an SDC% higher than your target, instead of taking that extra money out of the lemonade stand register, you should reinvest that cash to balance out the months in which starts come in with fewer pay-in-fulls or lower downs. Over time, with the growth that flexibility will produce, the VOLUME of Same-Day-Cash dollars will increase and compound to where it will yield a very nice semesterly or annual bonus for you. PAYMENT % OF TREATMENT LENGTH (PTL): this KPI monitors how closely your average financing terms are to the average estimated treatment length. In our office we use many systems that facilitate shorter treatment times (my office averages 16 months across all full treatment patients), so our PTL would reflect how close the average payment term is to that 16 months. Again, this allows us to manage risk appropriately by allowing the people who need

extended terms while, at the same time, not increasing aggregate risk and front office burden by creating a large chunk of overall business choosing long-term payment financing.

The gauges are actual numbers from my personal August 2016 dashboard showing our KPIs are nicely in line. I can allow any individual to choose the terms that are right for them by monitoring only these indicators and not micromanaging every single transaction. That’s how you intelligently create leverage to scale your business and not become overly cash poor in the process. I have one last thought to share. My first priority as an orthodontist is to take care of my patients as well as I possibly can and as efficiently as contemporary technology allows. There is nothing more rewarding. On the other hand, we run businesses and being smart when it comes to creating leverage and then managing It creatively is something we all need to succeed in the future. If we’re smart about it, we will achieve “the strategic application of energy to move mountains”…not to mention teeth.

Q1 • 2017 | TheProOrtho.com 67


ORTHOPUNDIT.COM

DOCTOR, PLEASE STOP ASSUMING By Dr. Nona Naghavi

A lot has been said and covered by many before me. Ben has done a tremendous job hammering it into our heads that some things we thought we should never do must be done in this day and age. I just want to share my experience with you. I can only speak for myself; I understand this may not apply to everyone. In 2011 I took a job in a busy practice in a location that was considered ideal: Underserved and not saturated. I learned a ton but ultimately missed living in a more urban environment. In 2012 I moved to a super saturated and overserved area with no jobs lined up.

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ORTHOPUNDIT.COM ASSUMPTION 1: THERE ARE NO JOBS IN SATURATED MARKETS. I agree that it’s not wise to do what I did, but just for the sake of this article’s title, let’s assume some states can guarantee your failure. I was able to not only find work but ultimately make more money than I did in 2011 while working fewer days. If you want to live in a town you love, close to family and friends, it IS possible, BUT you can NOT be picky. Doctor, if there are no jobs available, you go out there and create one for yourself out of nothing. I can’t tell you how many times I convinced an office to add Orthodontics to their services, something they had never considered before, and thus put food on my table. In 2013 I found out about Young-Docs, now Ortho101. I did almost everything Ben recommended, as much as was plausible in my business model. One of the most important being signing up with Medicaid. ASSUMPTION 2: MEDICAID PAYS TOO LOW. First of all, I get paid for just doing the consult. Can we say that about our non-Medicaid consults? (Please note this is state dependent). Secondly, I have no problem with cases that get accepted; I still make money. (But I bank on majority that gets denied anyway). I’ve learned to be efficient with my mechanics and finish on time. If the pay is low, I pretend I had to write off some of the money because patient went MIA or moved. Don’t we have that happen in our posh offices sometimes? ASSUMPTION 3: MEDICAID PATIENTS WILL ONLY START IF IT’S COVERED. So where do you think I do my same day starts? ASSUMPTION 4: I’LL HAVE TO USE CHEAP BRACKETS SO RESULTS MAY SUFFER.

The forum is full of posts about how and where to get cheaper brackets (and not all are asking because they are implementing Medicaid. Some are buying for their posh practices).

–––––––––––––––––– If you want to live in a town you love, close to family and friends, it IS possible, BUT you can NOT be picky. Doctor, if there are no jobs available, you go out there and create one for yourself out of nothing.

–––––––––––––––––– ASSUMPTION 5: RICH PEOPLE WILL APPRECIATE MY WORK MORE. There are two kinds of poor people; 1) only poor on paper (but really rich), 2) truly poor. They constitute 100% of my Medicaid patients. I can’t tell the difference because they both show their appreciation the same way. Truly rich and entitled people will find flaws that don’t exist first and then maybe appreciate. ASSUMPTION 6: MEDICAID PATIENTS DON’T SHOW UP TO THEIR CONSULTATION. I just showed Ben my work schedule for a random day in September. 42 consults. School is in session mind you. 30 of them showed up. Even with the 12 no-shows, wouldn’t you love to see 30 NP consults in 1 day? ASSUMPTION 7: MEDICAID PATIENTS BREAK BRACKETS AND DON’T BRUSH. I’m tired of hearing this. At least once a couple of month there’s a post about how to deal with a high-end mom not

accepting the fact that her spoiled rich son is chewing rocks and brushing only once a week. ASSUMPTION 8: MEDICAID PATIENTS WILL RUN OFF MY ‘OTHER’ QUALITY PATIENTS. I DON’T WANT MY LIVING ROOM FULL OF MEDICAID PATIENTS. This is very personal, but I’ll share it. I was a resident while pregnant with my first child. Unlike what I had planned for, I ended up with an emergency C-Section. Student, no insurance, no money. I will NEVER forget the stress I was under when presented with the hospital bill. I will NEVER forget the nice lady that came to my hospital room and said have you considered applying for Medicaid? Medicaid gave me coverage for ONE DAY only, my surgery day. I walked out with my baby. I was a DOCTOR on Medicaid that one day. There’s no “Them” and “Us.” Please treat everyone. So in 2012, in the saturated town I moved to, I met a GP in a mommy and me class who immediately gave me one day a month in her office. In the span of one year, I was providing Orthodontics for ten different offices with any combination of 1, 2, 3, or 4 days a month depending on their patient pool. ASSUMPTION 9: WORKING IN A GP’S OFFICE IS A DEAD-END BECAUSE: • You can get kicked out by owner at any moment. It’s in the owner’s best interest to help you grow and make the environment amenable to Ortho’s needs. Why would any GP introduce a disturbance into his practice only to destroy the good will he’s worked so hard for? Have I heard and witnessed horror stories? Yes. But I firmly believe that unless YOU are being a pain in the neck, no GP will intentionally make life hard for you. Their biggest fear is you leaving and their patients’ continuity of care.

Q1 • 2017 | TheProOrtho.com 69


ORTHOPUNDIT.COM • You’ll never get busy: I don’t know if you’ve noticed, but at least most offices that I work for have expanded and become their own multi-provider clinics. So I have at least three if not more doctors referring to me within each clinic. Am I busy? Yes. • Assistants aren’t trained: Do you only hire experienced assistants for your traditional office? Can you afford it in your start up? I had zero assistants for the first year. I did everything myself. Quite honestly I loved it, I didn’t have to correct anyone’s mess up, I was fast, and I did not waste any of my materials. After that, I got too busy and hired. I got lucky because in my area there are many foreign trained GP’s and Orthodontists who would gladly be my assistants. BUT, I have hired and trained from scratch too. • What about emergencies? I’m only there once a month: I’ve trained the GP’s assistants to take care of emergencies for me in between the Ortho days. I have NEVER driven to an office for an emergency call. Either the GP or their assistant has been able to take care of it for me. • How do I make appliances? Separator and banding is one week apart: I found a great lab who bands for me (extra charge but I’ve said goodbye to buying and fitting bands). Take impression and see you in two weeks or even four weeks. This lab is great. Appliances fit after four weeks no problem. • I can’t use appliances/iTero/iCAT that I want: Haven’t we learned we don’t need to buy SH*T we don’t need? How is this any different? • I don’t have Dolphin or TOPS or whatever software: I still use the PPT template I created to make my composites. If the front desk is capable of giving an appointment using whatever dental software they have and produce 70

a day sheet for me at the end of the day, that’s all the software I need.

some extra brackets/wires and such with you between the five offices you own?

• There’s no Ortho TC: I’ve tried everything including presenting the financial contract myself, in the beginning, all chairside. Now I have a head assistant that also doubles as my TC, all chairside. I noticed she had natural closing skills. I pay her $10 per SDS. There isn’t much space to spare in most multi-provider offices so I learned to keep things simple. I don’t need a TC room. By the way, even if I owned an Ortho office, I will never do open bay for this exact reason. GP offices with separate operatories are great for privacy and discussing fees/OH/compliance issues chairside.

ASSUMPTION 10: I WILL NOT TAKE OVER ANOTHER DOC’S CASES. I WANT TO START ALL OF MY OWN CASES. Why? I never understood this. In my first job, I took over hundreds of cases from someone before me. It was AMAZING to learn about the finishing phase of tx simultaneously as the initial phase. I saw what worked and what didn’t. I learned what NOT to do. It was rough, but I came out of it like a soldier who had seen too much but was also that much wiser. I was getting paid AND learning at the speed of light, from someone else’s work. Some of the offices I’ve taken over since have had patients who are overtime but accounts are paid. I can tell you there’s no better motivation to learn how to simplify and streamline your mechanics in detail when you know you are not getting paid until you finish this case FAST.

–––––––––––––––––– My best advice to new grads is “Know Thyself ”! Know your personality, your strengths and weaknesses. I have nothing against established practices. The guys and gals that kill it were born with that personality. They would’ve been successful in any business. They just happen to be an Orthodontist.

––––––––––––––––––

• I can’t carry my supplies everywhere with me: Some offices will want to purchase and own the supplies anyway. Some you have to use a carry-on bag for (and hence take home a higher % so it’s well worth buying a bag for!). Is that really so bad? Are all your satellite offices fully equipped? You’ve never had to tag along

It’s just BUSINESS

ASSUMPTION 11: I HAVE TO OPEN A PRACTICE RIGHT AFTER GRADUATION. My best advice to new grads is “Know Thyself ”! Know your personality, your strengths and weaknesses. I have nothing against established practices. The guys and gals that kill it were born with that personality. They would’ve been successful in any business. They just happen to be an Orthodontist. But remember, being the face of a practice leaves nothing private anymore. I see how people’s lives get wrapped up and consumed by the activity on their office FB page. From community involvement to marketing to games you have to play, and the image you have to portray 24/7..if success means being in front of the camera all the time then be sure that’s you. You might be happier just associating, and that is perfectly fine too. Oh and best of all? I do zero marketing.


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Smile for a Lifetime

Ben Burris, DDS, MDS Public Speaking & In-Office Education Email: bgbdds@yahoo.com Facebook: facebook.com/bgburris Twitter: twitter.com/bgburris

S4L.org info@S4L.org Facebook: facebook.com/smileforalifetime

In our ever changing world, those of us who want to run a dental business as opposed to owning a traditional practice (ie; owning a job) must think differently. Dental school and residency programs taught us how to be dentists but actually gave us a paradigm that makes it GLIžFXOWIRUXVWRWKLQNSURSHUO\DERXWGHQWLVWU\ as a business. Where and how does one learn how to move from a practice to a business? • Speaking for study groups and meetings Full day program: The Referral Revolution Half day programs: • The Same Sun Shines on Us All – Embracing Opportunity and Refusing Defeat • Short Term Orthodontics – Where Does It Fit?

Smile for a Lifetime Foundation is a charitable QRQSURĹľWRUJDQL]DWLRQWKDWSURYLGHV orthodontic care to individuals who may not have the opportunity to acquire assistance. Launched in 2008, Smile for a Lifetime Foundation aims to reach individuals with ĹľQDQFLDOFKDOOHQJHVVSHFLDOVLWXDWLRQVDQG orthodontic needs. The Foundation sponsors the orthodontic care of hundreds of patients each year. Smile for a Lifetime Foundation has participating orthodontists throughout the US. Each chapter has its own local Board of Directors who chooses patients to be treated by the Foundation.

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We are an orthodontic and dental practice VHUYLFHVĹľUPWKDWSURYLGHVDVVLVWDQFHZLWK the non-clinical business, marketing and administrative functions of orthodontic and dental practices, including marketing, billing and collections, purchasing/procurement, SDWLHQWĹľQDQFLDODQGLQVXUDQFHVHUYLFHV KXPDQUHVRXUFHVDQGĹľQDQFLDOUHSRUWLQJ The company currently serves nearly 350 orthodontic and dental practice locations.

%HIRUH7UX'HQWDGHQWLVWVZHUHWUDLQHGWRĹľ[ your teeth, straighten your teeth, whiten your teeth and even replace your teeth. However, dentists were not trained or equipped to diagnose and treat symptoms caused by the FRPSOH[IRUFHVWKDWRSHUDWHDQGFRQWURO\RXU head, mouth, jaw and teeth. With TruDenta, GHQWLVWVDUHDEOHWRTXLFNO\H[DPLQH\RXUELWH and range of motion. They can also show you the source of pain.

SERVICES: Practice Development Revenue Cycle Management Practice Management System Practice Procurement System Practice Accounting Business Insurance Practice & Equipment Financing Practice Marketing Facilities Management Human Resources Patient Insurance Planning Recruitment & Placement Practice Transition Real Estate Practice Check-up Newly in Practice

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TruDenta treatments are painless, pleasant and require no drugs or needles. Utilizing systems and methods perfected in sports medicine, your TruDenta dentist may be able to rapidly and painlessly resolve issues from which many patients have been suffering for years.

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It’s just BUSINESS

Shofu Dental Corporation Shofu Dental Corporation is a leading dental manufacturer of award-winning dental materials, instruments and equipment used by clinicians, hygienists, assistants and lab technicians. For nearly a century, the Company has been changing the landscape of modern dentistry by delivering innovative, smart VROXWLRQVWKDWIDFLOLWDWHJURZWKDQGSURĹľWDELOLW\ in practices and laboratories. Under the corporate philosophy of “Contribution to dentistry through innovative business practicesâ€?, Shofu is also committed to helping build a thriving society of healthy and beautiful smiles.

Practice Genius Patient Rewards Hub is an Engagement Marketing Suite featuring: Reward, Reviews, Social Media, Contest, Compliance, and Communication programs all rolled into an easy to use web application. Through your website or mobile app: patients redeem points, check reminders, participate in contests and games, take surveys or write reviews, all while in an engaging environment. 5HZDUGVDUHIXOĹľOOHGRQ\RXUEHKDOIDQGVHQW with a congratulatory note from your practice.

Trapezio Trapezio provides affordable online knowledge and training solutions for the orthodontic team. Packages can be easily FXVWRPL]HGWRĹľWWKHVSHFLĹľFQHHGVRI\RXU practice and team members can access material from any computer with internet DFFHVV&RPELQLQJGHFDGHVRIH[SHULHQFH RXUOHDUQLQJPRGXOHVEULQJWKHH[SHUWLVHRI LQGXVWU\OHDGHUVWR\RXUĹľQJHUWLSV

Ortho-Marketing Ortho-Marketing helps Orthodontists get More New Patients, More Referrals, More 5HYLHZVDQG0RUH([SRVXUH:HUROOXS our sleeves and get to know your practice and then come up with and implement unique marketing strategies to help you reach your goals. Services include: Website Development, Website Updates, SEO, Google Ad Words, Social Media Marketing, Reviews and Reputation Management, Email Marketing and App Development. If you want WRWDNH\RXUSUDFWLFHWRWKHQH[WOHYHO2UWKR Marketing can help.


The Practice Marketers Fast-Track your New Patient Starts with The Practice Marketers Done-For-You Direct Marketing System. Over 1,500 Orthodontists and Dentists Have Attracted Thousands of New Patients since 2001. You’ll love the results your Practice achieves when we deliver unique direct response mail to your community making you stand out above your competition!

LED Dental LED Dental provides a comprehensive line of QH[WJHQHUDWLRQLPDJLQJVROXWLRQVFRPELQHG with a commitment to white-glove service. From the VELscope oral screening system to Rayscan CBCT and 3Shape TRIOS intraoral scanners, LED Dental offers a complete digital ZRUNĹśRZWRHQKDQFHWKHZD\\RXFDUHIRU your patients. For more information, please visitwww.ledddental.com.

Benco Dental Benco Dental, headquartered in Pittston, Pennsylvania, is the largest privately owned, full-service distributor of dental supplies, dental equipment, dental consulting and equipment services in the United States. Founded in 1930 by Benjamin Cohen, the company has remained family-owned and focused on its unique mission to “delivcer success, smile after smile.�

Invisalign Align Technology is a global medical device company with industry-leading innovative products such as Invisalign clear aligners, iTero Intraoral scanners, and OrthoCAD digital services that help dental professionals DFKLHYHWKHFOLQLFDOUHVXOWVWKH\H[SHFWDQG deliver effective, cutting-edge dental options to their patients. The Invisalign system and iTero Intraoral scanning system and OrthoCADÂŽ digital services are available to general practitioner dentists (GP dentists), orthodontists, and other dental specialists. Align Technology provides training, clinical education programs, and the tools needed for orthodontists or GP dentists to adopt its innovative technology and offer the treatment options in their practices.

Dolphin Dolphin provides high-quality 2D/3D imaging, diagnostic, practice management, case presentation, and patient education software for orthodontists worldwide. Dolphin products WLJKWO\LQWHJUDWHZLWKGLJLWDO[UD\XQLWV&%&7 systems, telephonic solutions and Webenabled applications, and are compatible with the latest operating systems. Mobile and Cloud solutions are available. Backed with 24/7 technical support.

Specialty Appliances Specialty Appliances has been a leading full service orthodontic laboratory since 1981. Specialty’s innovative focus has led to many appliance inventions and laboratory technology advancements. Today they are recognized as the most advanced and H[SHULHQFHGGLJLWDORUWKRGRQWLFODERUDWRU\ Call Specialty Appliances if you value DSSOLDQFHTXDOLW\žWDQGWLPHO\GHOLYHU\

1-800-522-4636 Customer.service@specialtyappliances. com

NEOLab Website: Neolab.com Email: hello@neolabcom Phone: (978) 284-6501 Facebook: facebook.com/neolab NEOLab is your full-service orthodontic lab, DQGWKHFXUUHQWOHDGHULQGLJLWDOZRUNĹśRZ With personalized customer service, seamless intraoral scanning integration and 40 years of quality craftsmanship, NEOLab sets the bar for progressive orthodontic laboratories.

Braces Academy :LWK%UDFHV$FDGHP\\RXURIĹľFHFDQVDYHWLPH DQGLQFUHDVHHIĹľFLHQF\ZLWKSUHVFULSWLYHSDWLHQW education videos, preloaded elastic images, and customizable quick messages. This HIPAA complaint web-based software also offers a digital portal that allows GPs to refer directly to \RXURIĹľFHZLWKWKHFOLFNRIDEXWWRQ:LWKWKDW FRQWDFWLQIRUPDWLRQ\RXURIĹľFHFDQVWUDWHJLFDOO\ and proactively call and schedule a new SDWLHQWH[DPZLWKRXWZDLWLQJIRUWKHSDWLHQWWR call you, or worse, your competition.

Gaidge Banyan Banyan is a social media marketing SaaS company that created the only HIPAAcompliant patient photo and review sharing app and provides integrated websites and social advertising services. The app helps practices celebrate successful patient outcomes by posting HIPAA-compliant patient photos and reviews at the point of treatment.

Gaidge brings business analytics to orthodontic practices through an automated, cloud-based dashboard. Easy-to-read and interpret, Gaidge gives orthodontists the ability to investigate and analyze business performance with ease. This allows for strategic decision-making based on ‘big data’ insights and national trends. Gaidge is fully integrated with Cloud9, Dolphin Management, OrthoTrac, and Ortho2 management software.

DDS Multimedia DDS Multimedia provides dental practices with marketing techniques that turn the web into an advantage for their practices. We focus our website design and marketing efforts solely on the dental industry, and have developed proven campaigns that improve your patients’ H[SHULHQFHDQGLQFUHDVH\RXUSUDFWLFHőV bottom line.

Cloud9Ortho Cloud9ortho was developed from the ground-up as a browser-based system for management and imaging for orthodontists. It can use PCs, tablets, or Macs in their native PRGHZLWKQRRIĹľFHVHUYHUVUHTXLUHG)HDWXUHV have been added for Pediatric Dentistry. 7H[WLQJ HPDLOLQJDUHEXLOWLQIRUQRDGGLWLRQDO charge.


RESOURCES Carestream Dental

MidAtlantic Ortho

carestreamdental.com Facebook: facebook.com/CarestreamDental Twitter: twitter.com/CarestreamDentl About Carestream Dental LLC Since 2007, Carestream Dental has been a growing standalone company with strong HDUQLQJVDQGDKHDOWK\FDVKŜRZ3URYLGLQJ industry-leading dental equipment such as imaging systems and practice management solutions for dental and oral health professionals across the globe, Carestream Dental’s products are used by seven out RISUDFWLWLRQHUVWRGHOLYHUH[FHSWLRQDO patient care. For more information on dental equipment, or to contact a Carestream Dental representative, visit us online at www.carestreamdental.com. About Carestream Health Carestream is a worldwide provider of dental and medical imaging systems and IT solutions; X-ray imaging systems for nondestructive testing and advanced materials for WKHSUHFLVLRQžOPVDQGHOHFWURQLFVPDUNHWV For more information about the company’s broad portfolio of products, solutions and services, please contact your Carestream representative or call 888-777-2072, or visit www.carestream.com.

74

MidAtlantic Ortho continues to grow as an established industry leader with over 20 years of service to the Orthodontic specialty. We manufacture and distribute a full line of quality products including, metal and aesthetic brackets, molar bands, buccal tubes, wires, elastomerics and instruments. Among this offering are unique product brands such as our “Capsule� aligner case, Plier Brite cleaner and renowned instrument repair services. MidAtlantic’s commitment to quality products and responsive customer service consistently provide an overall better value to your SUDFWLFH,WLVWKLVFXOWXUHRIH[FHOOHQFHWKDWKDV further strengthened our relationships with Orthodontic specialists and opinion leaders throughout the country.

It’s just BUSINESS

Allure Ortho Our mission is to provide the highest quality products at the lowest possible prices, with the best customer service in the industry! Our H[SHULHQFHDORQJZLWKRXUIXOO2UWKRGRQWLF product line consisting of brackets, bondable tubes, molar assemblies and all peripherals, as well as top quality instruments, enables us WRVDYH\RXURIĹľFHDORWRIWLPHDQGPRQH\ Call today! 844-442-5587 www.allureortho.com

OrthoFi OrthoFi is designed to increase your starts and simplify your life. Our end-to-end solution streamlines onboarding, stimulates conversions, and takes on both insurance and patient processing & collection. OrthoFi practices are enjoying dynamic growth, EDODQFHGFDVKĹśRZDQGULVNDQGVPRRWKHU operations with insightful metrics to run their business.


CS 8100SC

FULLY TRACED IMAGES IN 90 SECONDS

FAST CEPH IMAGING MADE EASY FOR YOU © Carestream Health, Inc. 2016. 14874 DE CS 8100SC 3D AD 1116

With ultra fast high-resolution scanning and exclusive automatic tracing, the CS 8100SC system delivers fully traced cephalometric images in only 90 seconds. For more information, please call 800.944.6365 or visit carestreamdental.com


PROMO CODE:

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WHAT DRS. ARE SAYING


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The Progressive Orthodontist  

Q1 2017

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