Case Studies of Dental Practices

Aug. 1, 1997
Case Profile: This practice, located in a middle- to low-socioeconomic area in the southeast, sees a high number of emergency patients. After 20 years in practice, the doctor acknowledges that he is getting further behind each year. We were asked to determine the scope of the problem and the solution.

Sally McKenzie, CMC

Case Profile: This practice, located in a middle- to low-socioeconomic area in the southeast, sees a high number of emergency patients. After 20 years in practice, the doctor acknowledges that he is getting further behind each year. We were asked to determine the scope of the problem and the solution.

Symptoms: Like the legendary "dog being wagged by its tail," this practice is at the financial mercy of a demanding and self-indulgent staff. Making matters worse, production has leveled off in the last four-five years. And the final kick in the teeth ... accounts receivable are higher this year than ever before.

Observations: The doctor is a very nice person-too nice, in fact. Trying to please and wanting to be liked, he literally bends over backwards to avoid confrontation ... even when such contortions hurt him or his practice. Here`s what that means to his staff (two hygienists, two dental assistants and two business assistants):

Because they`ve all been with the practice for a long time, they get a lot of time off. To be exact, they`re paid yearly salaries and get three weeks` vacation, along with three sick days. Further, when the doctor is off, they`re off, and paid. Although staff salaries and profit sharing are eating up 27 percent of income, staff members are constantly whining about getting out late for lunch or at day`s end. (By the way, they`re seeing patients about 30 hours a week.)

Patients also get the better of Dr. Goodguy. When a patient says, "It hurts, Doc, fix it," the doctor often does the bare minimum, convinced that the patient can`t afford what`s ideal. On the other hand, sometimes the doctor provides more than the patient can afford.

Other areas of concern include:

- Emergency-patient numbers out proportion active patients.

- Delinquent-account phone calls have not been made in over a year. The individual accountable for these calls knows all the patients and is highly compassionate.

- Fees in this practice are only being increased every 2 1/2 years.

Discussion: This practice reminds me of a sinking lifeboat. While the crew is working on suntans and not keeping up with the need to bail water, the captain`s allowing more passengers aboard for a free ride. If major changes aren`t made soon, everyone will be forced to jump ship.

Treatment Plan: First, the doctor needs to address the time/salary issues that he should have explained to each employee when hired. He must say, for example, "The $19,000 a year salary you are paid is based on a 40-hour work week. While our schedules are fixed at seeing patients 30 hours a week, sometimes we will work additional hours to accommodate regular patients and emergencies. Some weeks, you may actually put in fewer hours-32, 34, 36 or 38 hours; but remember, your compensation is based on 40 hours per week."

As far as getting out late for lunch and at day`s end, to some extent, it`s part of the territory. Here`s what I recommend. The doctor and clinical assistant should do an analysis of their clinical procedures, identifying what is done by the doctor and what can be delegated. Procedure times will be communicated to the scheduling coordinator as either doctor time or assistant time. When scheduling, the coordinator is to identify doctor time by a specific color block to ensure that the doctor is not scheduled in two rooms at the same time. This system should benefit doctor and staff, and cut down on patient "wait" time in the operatories.

Next, the doctor should not begin any treatment over $200 without arrangements being made by the financial coordinator. If this can`t be done the same day, the patient should be rescheduled. In any event, the doctor should first present the treatment that he would recommend and then turn the patient over to the financial coordinator. If the patient cannot pay for the recommended treatment, the financial coordinator should say that she will ask the doctor if there is any alternative treatment as a temporary measure which would maintain the patient`s dental health until they can go ahead with the recommended treatment. It would then be the doctor`s decision to perform a "patch-it" procedure.

To cut down on emergencies and convert them to active patients, the doctor and assistant need to develop a game plan of "selling" the comprehensive exam. I actually advised this doctor to lay his hand on the patient`s arm and say, "Jack, I`ve known you for a long time and you know I love you, but I can`t-in good conscience-continue to take care of your teeth only when something goes wrong. I need you to make a commitment to me that you`ll come back to have your mouth completely examined. Leslie will make that appointment for you before you leave today and then we can get all these areas fixed so they don`t blow up in emergencies. I also want you to commit to come back on a regular basis to get your teeth professionally cleaned. Now is there any reason why you can`t do that?"

As for collections, the employee accountable for receivables was made aware of how her personality type affected collection efforts, causing her to procrastinate on patient-account work. Practice expectations regarding receivables are now to be as follows:

- The 57 percent accounts receivable over 90 days needs to be reduced to 18 percent;

- Delinquent-account calls are to be made to any patient who has not made a payment in 30 days (this employee will be expected to work four extra hours per week to reach those delinquent patients);

- Over-the-counter collections need to be 45 percent of monthly production, while the collection ratio needs to be over 100 percent for the next four months as past-due monies are collected;

- Accounts turned over to collection need to be adjusted off accounts receivable.

- Lastly, practice fees should be increased at least yearly (5 percent) if not twice a year (2 percent and 3 percent).

These recommendations working in tandem will ensure that nice guys don`t need to finish last.

Sally McKenzie is a Certified Management Consultant and president of McKenzie Management, Inc., a full-service, in-office dental management consulting company with clients across the U.S. and Canada. She can be reached at (800) 288-1877; e-mail [email protected]; or visit her web site at

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