by Sandy Roth
Suzanne had been practicing for days. Standing at the mirror with a gracious smile on her face, she envisioned the patient approaching her desk. "Lovely to see you again, Mrs. Jones," she rehearsed. "And how will you be taking care of your account today?" It all went so smoothly in her head. Mrs. Jones simply produced her credit card. Mrs. Jones painlessly paid the fees and went happily on her way.
Suzanne was as ready as she would ever be. All dental activity had ceased, and it sounded like Kelly was getting the patient's coat. "And how will you be taking care of your account today?" She practiced saying it just a few more times. It became her mantra.
Suddenly, the patient appeared. "Lovely to see you again, Maryanne. And will you be taking care of your account today?"
"No," replied Maryanne quickly as she walked past and out the door, "Just send me the bill."
Rats! She said it wrong! Instead of, "Are you going to pay?" she meant to say, "How are you going to pay." Suzanne chastised herself silently. Discouraged, she wondered if she would ever be comfortable talking about money. It seemed like patients always had some kind excuse. "Bill my insurance." "I forgot my checkbook." "I'll pay you when I get my tax return."
She knew Dr. Olivetti was counting on her to collect patient fees, but it was the hardest part of her job. Sometimes she felt guilty if she knew a patient had financial problems. And though she would never tell him directly, Suzanne thought Dr. Olivetti's fees were a bit on the steep side. She could understand why patients might delay their care as long as possible. Truth be told, she couldn't afford her own dental work if she had to pay for it.
Many team members have money issues similar to Suzanne's. But dentistry will always involve fees and payments; therefore, money and all of its ramifications can't be avoided. Although we might wish that a sign conveying expectations about fees would do the trick - "Payment in full is expected at time of service unless prior arrangements have been made"- such is rarely the case. Someone must speak with patients about fees and arrange for payments. Because the dentist is essential for other obligations in the practice, this responsibility is best delegated to other team members.
But who? Many larger practices choose to assign a single team member - a financial coordinator - the responsibility for patient financial arrangements. Still others expect front-desk personnel to handle these obligations while simultaneously answering the phone, greeting patients, and making appointments.
In these situations, other staff members often have little knowledge about fees and financial arrangements and are reluctant to discuss them with patients. Should patients express financial concerns or indicate an interest in exploring financing options with someone other than the designated employee, their concerns could easily go unaddressed. With no training and little practice, non-designated staff members are not likely to develop the skills or confidence necessary to engage in effective discussions about money.
If, however, every team member were skilled at addressing financial issues with patients - both proactively and in response to specific questions - the likelihood of confusion, misunderstanding, and stress could be minimized. For this reason, our exploration in this installment of our series is intended for every team member. Dentists must be involved in establishing business guidelines, providing proper training and support, and ensuring that practice resources are sufficiently available. Because so many team members are reluctant to get involved in patient finances, I'm encouraging each employee who has contact with patients to suspend resistance to money issues, at least temporarily. I request this, because I know that while many team members are fearful of this role, still others are, frankly, dead set against it. Yet, I believe I can make a strong case in favor of a different perspective or at least an awareness of the principles that impact discussions about fees.
Let's begin by outlining three important principles:
- Principle one: Almost anyone can afford almost anything he or she wants.
- Principle two: Almost no one can afford everything he or she wants.
- Principle three: Almost no one wants everything he or she can afford.
We live in a privileged society; most patients can afford many of the things they want in life. But all those patients must make choices about the many possible ways to spend their dollars. For example, my parents could afford a 2001 Harley Davidson Softail Deuce motorcycle, which lists at a price of $16,235. Since they don't have $16,235 lying around, they would have to figure out from where that money would come. They have a few choices. They could sell their car or some furniture. They could even sell their house. If they wanted this motorcycle badly enough, I am certain that they could raise the cash or even find some financing to help them make payments. I suspect it is unlikely that they would do that, however, because they don't want a Harley Davidson Softail Deuce. The point is: If they wanted one badly enough, they could figure out a way.
Decisions about how to spend financial resources involve a process that pits the perceived benefits of a purchase against the perceived costs so that a relative value can be assessed. The concept of "relative value" is important. Most of us are unable to determine the actual worth of many things we purchase. My parents, for example, have no way of knowing if the metal, leather, engineering design, and roadworthiness of a Harley Davidson Softail Deuce is actually worth $16,235. They only know whether it is worth that much to them. Now, let's say they are weighing the purchase of a Harley. Their decision will be based in part on their assessment of the value they would receive from the motorcycle vs. what spending that money in other ways would provide. The pleasure of owning a Harley weighed against, say, a motor home costing the same amount is what determines the relative value. If they believe a motor home would provide a more enjoyable, safe, and comfortable vacation vehicle than a Harley, they are likely to value the motor home over the motorcycle.
This is a simple concept and one most of us can easily understand. But I often hear another perspective from dentists and staff members. It goes something like this: "Jonathan claims he can't afford the dentistry we recommended, but I don't buy that for a minute. I happen to know he just bought a new car and that he's taking his family to Disneyland for a vacation this summer!"
In this instance, something very dangerous has crept into the thinking of the speaker: disapproval. If we remember that Jonathan probably can afford what he wants but likely can't afford everything he wants, we must acknowledge that Jonathan has chosen an automobile and a family vacation over recommended dentistry. He perceived the relative value of those choices to be greater.
The patient is in the best position to determine what is in his own best interest. Although you may be the expert on clinical dentistry, Jonathan is the expert on himself. If you confuse that distinction, you will overstep the boundary and tread on dangerous ground.
Dentists are in a position to make clinical recommendations by diagosing conditions and by understanding appropriate courses of treatment. It's up to the patients to determine if the results are important enough to designate their funds for this purpose.
I emphasize the financial decision-making process, because how you think about your patients and their money habits significantly influences your approach when discussing fees and making financial arrangements. If you think everyone should just find a way to afford needed dentistry, you will have greater difficulty discussing money without your own disapproval seeping through. Or, if you can't imagine how people can afford the high cost of dental services, you will have an equal amount of difficulty, but for a different reason.
Spending decisions are easier to understand when you recognize that choosing to purchase something means reallocating discretionary funds from another purpose. Many patients will say, "I'll do it when I find the money," but hardly anyone ever stumbles upon a wad of bills. Patients must make choices about how to allocate their limited resources. Those choices are based on what they perceive to be in their best interests at that moment and are heavily influenced by their personal value system - not yours!
Every patient expects a fee for your services; they also suspect you would like to be paid! Although patients may hope the fee will be minimal, no one thinks for a second that dental services are free, even if they have dental benefits through their employers. Since you know there is a fee, and your patient expects that there will be a fee, it makes no sense to avoid discussing it. In fact, you must initiate a discussion about fees rather than wait for the patient to ask. This is your obligation.
Many team members tell me they are reluctant to introduce the topic for fear the patient will think "we are all about money." It is true that harsh, aggressive language can seem insensitive, particularly when patient-centered issues seem to be disregarded. Using gentle language, however, and addressing important issues other than money, goes a long way in establishing your sensitivity and intent with patients. Address the issues of fee and financial arrangements learly by bringing up the subject: "Mrs. Jones, I'm sure you will want to know what to expect in terms of a fee and how we will ask you to take care of your account with us. The fee for this service is $X. Our first choice is that you take care of it at your next appointment. Will that work for you?" (I know many people have begun to call the fee an "investment," but, frankly, I think this sounds silly.)
If you have a preference about how the fee is paid, say so. If you don't care, let the chips fall where they may. If you don't ask, the answer is almost always "no," so what have you got to lose? If the patient says that paying in full ("up front" is a term that sounds rude; you might want to avoid it) at the first appointment isn't possible, ask what will work. If the patient's request won't work for you, say so and offer another choice. "Gosh, that isn't something that will work for us. But I have another suggestion to offer." Once you have reached an agreement, always confirm it in writing. Make a specific notation in the chart or on the computer, and create a system that gives the patient a written overview of the fees and the arrangements to which you have agreed.
Patients will often wish the fee were lower, much like we wish the cost of groceries, gasoline, or soccer uniforms were less. Have you ever said to yourself, "Darn! That pair of shoes doesn't cost as much as I hoped they would. I don't think I'll get them." Of course not! So prepare yourself; many patients have a bit of a struggle over fees. Remember, however, that it is their struggle - not yours! You cannot own your patients' dental problems or their financial issues.
Patients deserve to know the full fee and to reach an agreement about that fee before they are asked to commit to an appointment. It is unfair to omit either of these steps. Good restaurants don't allow patrons to order and consume a meal without knowing the cost and for good reason: they want diners to return! No respectable, service-oriented industry would offer an embarrassing experience that catches their customers unprepared.
Dentists who fail to regularly make provisions for fee and financial arrangements relinquish their right to expect the fee to be paid in a specific way. You can only hold someone accountable to an arrangement to which they have agreed. Do not put your practice's financial stability at risk; don't allow avoidable surprises to put your patients in a difficult situation.
Discussing fees and attempting to make financial arrangements prematurely is as grievous an error as failing to do so at all. Consider the following scenario: You are spending a leisurely Saturday at the mall. You're not really looking for anything in particular; you're just browsing. An aggressive salesperson spies you and suggests you try on a particular outfit she thinks was just made for you. You hate the outfit. You don't want it. She tries a new tactic, telling you that the outfit is on sale at 25 percent off and that if you open a store account that day you'll receive an additional 15 percent off. What part of "I don't want it" does she not understand? Indeed, if the dress is ugly, the cost doesn't matter.
There is an orderly sequence to work through questions about dental care; when that order is shuffled, trouble will follow. If the dentist and team members follow the appropriate order, they will be in a better position to guide the patient. Consider the following hierarchy of questions when addressing fees and financial arrangements:
- Does the patient believe there is a problem? Patients will not be motivated to solve a problem they don't believe they have. Thus, the first step in the decision-making ladder is to learn whether the patient has ownership of a problem. This is quite simple to do, but is often overlooked. The dental team often rushes to a premature solution and leaves the patient behind. Ask each patient what problems he or she is experiencing. Listen and learn first; offer your perspective later.
- Do you and the patient agree on the problem? If the two of you agree on the problem, you are on common ground; however, if you disagree, you must sort out your differences before moving on to the next step. This doesn't mean the patient must understand the problem in the same way you do. The problem affects the patient emotionally; it impacts the dental team intellectually. The dental team and patient must be working on the same problem - even if for different reasons.
- Does the solution make sense to the patient? If it does, you can proceed to the next question. But if it doesn't, don't take another step forward until that patient can embrace the solution. Many dentists create confusion by using overly-technical language and, oddly, by over-explaining. If the dentist can't release himself from this tendency, he must remove himself from this part of the process and allow a more patient-friendly team member to assume this role.
- Does the patient have confidence in you to provide the solution? The answer is often assumed and therefore seldom asked. In some cases, a patient may believe a dentist is skilled, yet not feel comfortable with her style. Other patients may question a dentist's clinical competence, attention to detail, or even the competency of the staff, even though they enjoy the dentist's personality or chairside manner. Confidence in both skill and style are key.
- Does the fee seem appropriate and fair to the patient? It is only now that we begin to deal with financial issues, but look how far along you are. A patient may agree on the problem, the solution, and that you are the right practice, yet not place the same value on the service or outcome that your fee suggests. The process of determining value is purely subjective and has nothing to do with good or bad values. Each person has different priorities. Some people value their physical health very highly, while placing a lesser value on emotional health. Others have a greater personal investment in the quality of their family life than their contribution to community causes. Because you can't judge another's priorities, you must be prepared for some patients to value some services less than others. Fees begin to sort that out for patients. The price-testing process accompanies every decision patients make.
- Is the fee affordable? This is purely and simply a cash-flow issue. Some patients may successfully work through each of the earlier questions, only to be stopped cold at this point. Indeed, for some patients, there are not enough financial resources to pay for even the most compelling of solutions.
Here are some examples illustrating how the question ladder might be used:
What should you do when a patient asks for a predetermination? If you and the patient have addressed each of the first five questions and the predetermination is designed to help the patient address cash flow issues, it makes sense to help find that answer. However, if the patient doesn't own the problem, or if you don't agree on the nature of the problem or the appropriateness of the solution, or if the patient isn't confident that you are the right dentist or is unsure the fee is a fair one, you have no business discussing cash-flow issues at all.
If a patient says she can't afford the dentistry you have suggested, should you offer financing or to do the work in stages? Not if the patient doesn't yet own the problem. Not if you have failed to agree on the problem and the solution. Not unless you have determined that the problem is one of cash flow.
The building process is simple and the challenge is clear: When the patient is stuck, return to the point at which you have agreement and begin moving forward from there. Take things in the right order, don't rush, and be patient with the process. It must be honored.
To learn more about how you and your team can develop stronger and more effective 0communications skills, call Sandy Roth at (800) 848-8326 or send her an e-mail at firstname.lastname@example.org to request a catalogue of learning resources.
Guided personal exercise
It's time to take stock. You might begin by asking each team member to answer these questions on his or her own, then compare the answers at the next team meeting. This will tell you what information your team members have, what they need to know, and how they can be more involved in discussing money with patients.
- How do patients learn about fees in your office?
- When do they learn the fee for a service or procedure?
- What financial arrangements is your practice prepared to accept?
- How are fees determined, and where is that information found?
- What is the fee for an initial appointment in your office? When do patients learn that fee? How are they expected to pay that fee?
- What is our total accounts receivable? How much is outstanding after four months?
- How much of the accounts receivable is covered by a specific payment plan?
- How much is owed with no specific plan for payment?
- What role does each team member have in addressing fees and discussing financial arrangements with patients?
- What do you now want to change about the way you discuss money with your patients?