Louis Malcmacher, DDS, FAGD
You have just finished a beautiful crown and bridge case on Mrs. Jones. Six anterior units went in after two impression appointments, three bisque bake try-ins, and two seating appointments. She is finally happy, you are proud of your work, and your staff is happy to be done with Mrs. Jones. Was it worth it? Did you make any profit on this case, or did you lose money? Did your fee justify your work?
Crown and bridge procedures are not just routine; most of us do a lot of them. They have become routine to us because we see the same thing every day we practice. Your staff begins to feel the same way, because it becomes boring ... just another impression, just another temporary, just another crown prep. What you must remember, though, is that no procedure is routine to your patient. He is finally going to get the broken tooth fixed that has been bothering him for months. It's been cutting his tongue, he hasn't been able to chew on that side of the mouth, and every once in awhile it gives him a few twinges of pain. Now that he is getting it taken care of, he is really looking forward to being able to chew comfortably on that side of his mouth again. He is looking forward to not waking up in the morning feeling like his tongue has been sliced to bits. To the patient, this is not a routine procedure — it is a life-changing, life-enhancing measure that can be quite exciting. If patients come into the dental office excited about having their problems fixed and we just sit there and yawn through the entire procedure, we lose a tremendous opportunity to show them how exciting, easy, and fast dentistry can be in the year 2002.
By the way, you and I are the same as our patients. Let me give you a nondental example. The showerhead in my master bathroom had been leaking slightly for months. I had been giving lectures and traveling a lot, so I just hadn't gotten around to having it fixed. Every day after I would take a shower, I would literally pound the shower handle to try to stop the leak. Day after day, week after week, month after month, this little dripping noise really annoyed me until it turned into a river whose flow I could not stop no matter what I did.
I finally called the plumber. When he came to fix it, he said to me, "This really must have been an annoyance to you; you'll feel so much better after I fix this." That simple statement made me feel so good about my decision to get my showerhead fixed (even though I really didn't have a choice at that time). The next time I need a plumber, I am definitely going to call that same fellow. He made me feel like a genius, even though I certainly wasn't one for waiting so long to fix the darn thing!
Let's now transfer this same situation to the dental office. A patient comes in, he has been annoyed by a broken tooth for a while, and he is finally ready to get it fixed. Instead of treating the procedure as just another boring, routine crown, how about both you and your staff say to the patient, "Gee, this must have really been annoying you for a while. You'll feel so much better after we fix this for you. The tooth will function better, and it will look like a million bucks." In those simple statements, you've given that patient the confidence and reassurance he needs that he is making the right decision to invest money in this tooth. He will also feel good about investing with you! Statements like those build patient loyalty. And, yes, there is still such a thing as patient loyalty. Even in our era of managed care, which, thankfully, remains a pretty small piece of dentistry, patients will be loyal if you take care of them, show them that you take care of them, and let them feel that you take care of them. It's always the little things that count when developing loyalty and trust.
Another way to increase the profit from crown and bridge is to reduce the associated overhead. Of course, the greatest overhead with these procedures is the lab fee. In the United States, the dental laboratory business has become very competitive and global. There are some advantages in using a local laboratory, such as pickup and delivery convenience, as well as having the lab technician come to your office to take specific shades of the patient's teeth. The disadvantage of using local laboratories is that you are limited to the talent and artistry available in your immediate area. There are many good ones locally as well as nationally, but not all of us are blessed with wonderful local talent. Thinking of the dental laboratory industry as a nationwide business gives you much greater options in terms of seeking out the best dental technicians. Another big advantage of using an out-of-town laboratory may be price, if the work quality is the same as what you get from your local lab.
The laboratory business is very competitive. One technique that many dentists use to keep their bills reasonable is to compare fees among different labs at least once or twice per year. Make a list of your most common laboratory procedures and fax them to 10 different labs to get their best price based upon the number of units per month that you do. You will be amazed at the differences in price, as well as what laboratories charge for add-ons. These add-ons — such as pouring models, mounting models, setups, deliveries, remakes, and tax or shipping — can greatly influence the price of each crown you do. This is why you have to be diligent about comparing laboratory costs. Complete this exercise the next time your favorite lab wants to raise fees. This is where competition can work for you to keep your overhead down. You can use the information from your informal survey to negotiate with your current lab, particularly if you are happy with their quality and if they can keep their costs reasonable.
Let's talk about overhead control when it comes to the patient fee for laboratory-based restorations, such as crown and bridge procedures. The general rule is that your patient fee for a laboratory-based restoration should be six to eight times what the actual lab fee is. For example, if the lab charges you $100 to fabricate a single crown, then your patient fee should be in the range of $600 to $800 for that same crown. If your patient fee is only $450 to $500, you are basically at a break-even point, and you may even be losing money with every crown that you do. This is why managed care is so difficult to maintain in relation to crown and bridge procedures. Unless your lab is taking the same 20 percent fee cut that managed-care plans want your office to take on these procedures, you will lose money on every crown. In that scenario, all of the other procedures you do are basically offsetting the loss from your crown and bridge procedures. Crown and bridge is challenging enough without making it a loss leader. No procedure in your office should be a loss leader, especially not a bread-and-butter procedure such as crown and bridge.
If your laboratory cost is $200 for each crown, then your patient cost needs to be between $1,200 and $1,600 to absorb the laboratory fee and your office overhead. Many doctors make the mistake of insisting on a very high-quality laboratory that charges high fees, but then don't reflect those same costs in their final fee to the patient.
Speaking of patient fees, you need to reevaluate all of your fees at least once per year. If you don't, you will have no idea whether or not the procedures you do are profitable. Many dentists do not look at their fee schedules for years at a time, only to realize later that they are either low or inadequate compared to other costs that have risen during that same time.
Only good things can happen when you raise your fees 5 to 10 percent. First of all, you instantly become more productive and your overhead goes down. Many dentists are afraid their patients will leave them en masse, but I assure you they will not. Most patients already think that dentistry is expensive, but they understand that you have to raise your fees at least in accordance with the cost of living. If you were charging $600 for a crown and now it is $660, most patients won't even blink. Sure, a few will complain and some may even leave your practice, but those are probably the patients you didn't want anyway. Often they are the patients who complain and try to nickel-and-dime you. They are the ones who usually don't pay on time or at all. It is important to set your fees at a level where you are comfortable providing the quality dentistry that you want to accomplish. Don't get caught in a situation where you have a high laboratory fee and a low patient fee. This will immediately increase your overhead and can slowly eat away at a dental practice's bottom line.
One area where you can immediately increase the profitability of crown and bridge procedures is in the cementation techniques you use. Clinical Research Associates has estimated that a dentist's time in terms of overhead is approximately $10 per minute. With crown and bridge procedures, it is essential to work as accurately as you can so that at the final seating of the restoration, a minimum of adjustment is needed. Time is money when it comes to the dental practice. In this aspect, we are much different from the legal profession, which also uses the "time is money" adage. To a lawyer, "time is money" means that he should drag his feet and try to bill as many hours as possible, because the longer it takes, the more money he can bill and the more money he makes. In dentistry, we are paid by the procedure, not by the amount of time spent. If you charge, say, $500 for a crown and it takes you more time than you thought, you will lose some of the profit from that procedure. If you can accomplish the same procedure in less time, then your overhead is lower and you will be more profitable.
One of the biggest time-wasters for crown and bridge procedures is crown adjustment and seating. If it takes you 20 minutes to adjust and seat a crown, then you have an additional $200 of overhead in that procedure, which is nearly impossible to recoup. You have essentially lost money on that procedure. If, however, you have worked with your laboratory and you have your impression technique down pat, then your crowns should go into the mouth with a minimum amount of adjustment and be inserted and seated in five minutes. This requires a great team effort for you, your staff, and your laboratory, but it is worth the time and effort to ensure that your crowns go in flawlessly.
For cementation, there are many resin ionomer cements that will do the job so you can have the patient out of the chair in five minutes or less. Resin ionomer sets can be fast-setting, release flouride, eliminate postoperative sensitivity, and are very strong. Some examples include Infinity from Den-Mat, RelyX by 3M ESPE, and Fuji Plus from GC America.
Crown and bridge procedures are the backbone of every dental practice. But don't be fooled. Just because the fees run into a few hundred or a few thousand dollars does not mean that these are profitable procedures unless you really work with your team and work on your overhead. Use these suggestions to help reduce your overhead, increase your profitability, reduce your stress, and you'll have more fun doing dentistry.
