Think twice before referring profit out of the practice

Feb. 6, 2013
It’s no secret that the recent economic downturn in the U.S. economy has affected the dental community.

by Brad Dykstra, DDS

It’s no secret that the recent economic downturn in the U.S. economy has affected the dental community. An observable trend since the start of the great recession is that general dentists are sending fewer patients to dental specialists and are doing more procedures in-house.

General dentists have begun to recognize the benefits of increasing their treatment options, improving their clinical skills, and keeping patients in the practice. This has resulted in a decrease of referrals to specialists. So, out of necessity, specialists have also increased their treatment options and started to do more procedures that were previously done only by the GP. As always, change can provide opportunity for success or failure.

Several areas are available to general practitioners to increase their business and revenue. Learning to do more of the procedures historically referred out can have a great impact on the bottom line. The list of potentially retained dental procedures may include Invisalign, Six Month Smiles, oral surgery, implant placement, Laser perio treatment (LANAP), or endodontics, to name a few. In these situations, case selection and proper training are the keys to success or failure.

It is a well-known fact that patients accept treatment much more readily if they can have it done in one dental office. How many times have you made a referral and the patient failed to keep the appointment? The truth is that patients generally prefer to have work done in their own dental office rather than by some unknown specialist. The more treatment dentists can provide in-house, the more receptive patients will be and the more profitable the practice can be.

Aside from the financial implications, being the patient advocate and primary care provider is the most important role of the general dentist. In the medical world, the model that coordinates the patient’s health-care needs is coming into vogue. Similarly, in the dental world, we should consider a dental practice as a patient’s dental home. Patients know us, like us, and trust us.

A dentist’s obligation is to be the quarterback watching over the patient’s complete dental care, and to use specialists only when it is in the best interest of a patient. Even when a dentist does refer, he or she should be specific in the treatment needed and the desired outcome.

One result dentists want to avoid is the specialist taking over more of the patient care than requested. An example may be when a patient is referred for an endo or perio evaluation, and the specialist decides that the tooth is not restorable. He or she may then extract it, place an implant, and in some cases even restore it. This does happen if the dentist is not vigilant.

Endodontic therapy is one such procedure that is increasingly being kept in-house. It certainly falls within the realm of a general practitioner’s training and area of expertise. Many training courses are available to hone dentists’ skills. This article focuses on how keeping more endo in the practice benefits patients most of all, but also the practice. This is true not just for the doctor but the team as well.

The endodontic needs of any general practice can vary from week to week, but are always significant. For the sake of discussion, assume there is open time in the schedule that would go unused and can never be recovered and that you have one endo case a day (200 cases a year). If each case is referred out, there is no benefit for the practice and the patient is served only if he or she is willing to see someone outside of your office.

However, if 75% can safely be retained and treated in the office — 150 cases at an average fee of $850 per case — one could expect increased revenues of $127,500. All of the fixed costs are already covered since they accrue whether you’re seeing a patient or not.

For endo procedures, the only added costs are supplies, about 6% on average, or $7,500 annually. The result is a $120,000 increase in net profit for the year. This is certainly a good option, especially when cases are selected wisely and not out of desperation.

Appropriate case selection for your skill level is something that can be easily learned. Many cases are straightforward when the canals are clearly visible on radiographs and the roots are relatively straight. The cases that present with curved root anatomy or possible total canal calcification may best be referred to an endodontist.

If there are any doubts about the internal anatomy of the tooth, a small field of view CBCT with the CS 9000 should be obtained. You can now examine the root morphology and make an informed decision on whether to treat, refer for endo, or possibly because of root fractures or other findings, refer for extraction and implant placement.

When it comes to failed root canals, the CBCT becomes invaluable. Before any failed RCT is considered for a re-treatment, the scan is examined for possible missed canals, especially MB2s on upper first molars, root fractures, or other contraindications to predictable re-treatment.

If the problem seems simple, such as an incomplete fill or missed canal, forward the scan to the endodontist for review, and then have this person tell you the best probability of successful re-treatment. If the endodontist gives a positive prognosis, only then is the patient referred for re-treatment.

This is a cost- and time-effective method for all involved. It helps ensure the best treatment outcomes for patients while minimizing inconvenience. The patient does not have to make a trip to the specialist, only to be charged and then informed the prognosis for re-treatment is poor. This keeps the specialist from giving the patient the bad news. It also keeps the patient in the practice, or if referred, keeps the general dentist in charge of the complete treatment sequence and patient outcome. Everyone wins.

When the economy is weak, there is a choice to participate in the downturn and hunker down until the storm passes, or create and live in your positive economy. I chose not to participate in the downturn in Michigan’s economy during the last few years, and I have experienced a steady yearly growth of 13% in 2011.

I’ve learned that my perceptions of how things are affect my decisions and outlook, and ultimately, become my realities. I’ve made the decision to view life as the glass half full, not half empty. Living out of a feeling of abundance and gratitude, and not shortfall or want, is the better place to be.

Choosing cases wisely is the key to making this a profitable and emotionally rewarding decision. Poor case selection and unsuccessful treatment is a costly proposition. And here’s a final word of caution. Patients can tell if you’re desperate and under financial pressure to sell a case, do the endo, etc. If they see this, they won’t buy.

Bradley Dykstra, DDS, is a general dentist in private practice in Hudsonville, Mich. He is a graduate of the University of Michigan’s dental school and received his MBA from Grand Valley State University. Dr. Dykstra speaks on integrating technology into the dental office, and consults through his company, Anchor Dental Consulting. Reach him at (616) 669-6600, or send an email to [email protected].

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