The Bio-Engineering Co.

Do you use plastic aligners to treat some or many of your cases?  Are the results you attain with plastic aligners satisfactory?  Do you feel that the lab cost of aligners is a bit too high?  Have you ever considered making your own plastic aligners?  Well maybe this pearl can help you decide.

Not every orthodontist feels comfortable using plastic aligners.  Many feel comfortable only treating easy cases and some are comfortable treating most cases.  Whether you are an expert using plastic aligners or not, there is one problem everybody has…the lab costs.  Invisalign lab costs range from $400 to $1,900.  There are other aligner companies with similar quality such as Ormco’s SPARK, 3M Clarity, etc.  They all have their good and bad points and prices, but in our financial analysis below we’ll use the Invisalign lab prices.

But, what if you produced your own aligners: is it really worth the cost and effort?  We will look at the various lab costs below for the full spectrum of plastic aligner treatments.

To produce your own aligners you need to be able to do an initial scan, use aligner software to design each 3-D model printout, use a process to clean and cure the 3-D models and then use a heat-vacuum machine to create the actual aligners.  For maximal equipment costs we will use the cost of the iTero scanner, the Sprintray 3-D model maker, Cleaner and Curer equipment, the Great Lakes Biostar to create the aligner, and the Dremel for finishing the aligner.  After that we will substitute other equipment, etc., and calculate a minimal cost.

The prices below will be used to calculate the MAXIMUM equipment cost per U&L set of aligners:

$  iTero scanner = $14,000  (the very portable Carestream digital scanner is $7,000 - $25,000)

$  Sprintray 3-D Printer = $7,500 (the Envision One cDLM costs $17,000, but can print up to 6 sets of aligners in the same time the Sprintray prints one set)

$  Sprintray Pro-Wash = $1,500

$  Sprintray Pro Cure  = $1,000

$  Great Lakes Biostar  = $900 

$  Dremel Tool for aligner finishing = $100

$  Total cost = $25,000

$  Assume that the equipment will create at least 5,000 U&L aligner sets

$  Thus the maximum equipment costs is $5.00 per U&L aligner set

The prices below will be used to calculate the MINIMUM equipment cost per U&L set of aligners:

$  iTero scanner = $0.0 (since you already have one for your present Invisalign cases)

$  Sprintray 3-D Printer = $7,500

$  Sprintray Pro-Wash substitute = $200 for ultrasonic cleaner

$  Sprintray Pro Cure  = $1,000

$  Great Lakes BioStar substitute  = $400 for Tru-Tain Pro-Vac

$  Dremel Tool for aligner finishing = $100

$  Total cost = $9,200

$  Assume that the equipment will create at least 5,000 U&L aligner sets

$  Thus the minimum equipment costs is $1.85 per U&L aligner set

The supply prices below will be used to calculate the SUPPLIES cost per U&L set of aligners:

$  Resin for models $150/bottle for 30 models (15 U&L sets) = $10/set

$  Essix materials for aligners at $150 for 100 trays (50 U&L sets) are $3.00/set

$  Isopropyl Alcohol ($30/gal) is for 15 U&L set washes is $2.00/set

$  Thus the supply costs are $15.00 per U&L aligner set

The in-house STAFFING costs below will be used to calculate the cost per U&L set of aligners:

►  Initial U&L Scan is about 20 min

► 3-D Printer software usage is 0 min (done by doctor, similar to online Invisalign software usage)

► 3-D printing 2 min for model processing

► Model cleaning is 2 min for model processing

► Model Curing is 2 min for model processing

► Aligner Vacuum-create and trim is 7 min

► Thus the total staffing time for one set of U&L aligners is 33 minutes

► At $25/hour ($0.42 per minute) for 33 minutes the staffing cost is $13.75 per U&L set of aligners

► Assume that the in-house lab space is already there and not an extra cost

Thus, the total MINIMAL cost per U&L set of aligners is $30.60 and the total MAXIMAL cost per U&L set of aligners is $33.75.

Thus, the Invisalign lab cost compared to in-house lab costs per treatment are:

$  Full Cases of 30 sets: Invisalign = $1,900; In-House lab is $900 to $1,000 [50% savings]

$  Moderate Cases of 20 sets: Invisalign = $1,500; In-House lab is $600 to $675 [55% savings]

$  “Light” Cases of 14 sets: Invisalign = $1,000 - $1,300; In-House lab is $425 - $475 [60% savings]

$  “Express” Cases of 7-10 sets: Invisalign = $400 - $700; In-House lab is $300 - $350 [40% savings]

But, if you do hundreds of aligner cases per year at a 40% outside lab discount the cost difference is:

$  Full Cases of 30 sets: Invisalign = $1,150; In-House lab is $900 to $1,000 [20% savings]

$  Moderate Cases of 20 sets: Invisalign = $900; In-House lab is $600 to $675 [30% savings]

$  “Light” Cases of 14 sets: Invisalign = $600 - $800; In-House lab is $425 - $475 [35% savings]

$  “Express” Cases of 7-10 sets: Invisalign = $250 - $400; In-House lab is $300 - $350 [0% savings]

The bottom line is:

If you do about 100 cases per year the in-house lab cost savings is greater than 50% and worth the effort.  Your lab staffing would only be a 0.75 staff member for 100 cases/year.

If you only do 20 cases/year the up front investment in equipment may not be worth it it, although over 20-30 years it may be.

If you do hundreds of cases/year the savings is only about 25% and may not be worth the effort to do it yourself, unless you want to maintain a large lab of about 2 to 3 staff.  The larger lab than usual would add to the cost/set of plastic aligners and be less than a 25% savings.

Also refer to the pearl “How Much can Plastic Aligners Increase Your Net?” at: http://www.thebioengineeringco.com/index.php?option=com_k2&view=item&id=172&Itemid=766

Have your patient visit communications suffered because of the pandemic?  Do the family want more information at their visits than they are getting?  Maybe this pearl can help improve your communications.

Pandemic social distancing and crowd cluster restrictions is taking its toll on practicing orthodontics today.

In the "good old days" patients would walk in, brush their teetha and wait on-deck to be treated as their families waited in the reception area.  Today, the patients and family wait in their cars until called by cell phone.  Once called, the masked patient is met at the door, has their temperature taken, is asked questions, is then escorted to the tooth-brushing area and finally to the chair.

Refer to the pearl "Making Patient Visits More Exceptional" to see how much patient traffic procedures have changed.  Now back to our discussion.

When checking out, the assistant can't escort the patient to the reception area and discuss what was accomplished today.  The family is typically called on their cell phones and asked for help with the patient's next visit.  The family and reception staff misses their usual communications that make the visits more social and help promote the practice.

When the family has concerns about treatment they have little access to the doctor to voice them and may become frustrated about it.

But there is a way to improve this situation—immediate doctor communication with the family at the end of each visit.  This not only makes the family feel better about the treatment, it makes them feel more important and want to promote the practice.  Here's how it works:

At the end of each visit, as the patient is being dismissed, the doctor calls the waiting family on his/her hands-free "visit" cell phone and tells them what has occurred on this visit and any important instructions (better brushing, doing well with the removable appliance, etc.).  It is best to do it while with the patient, but can be done while washing and gloving up to save time in busy practices.

You may think that this is a large amount of time to add to your busy day, but it isn't.  It only takes about 30 to 60 seconds for the average communication.  And if treatment time is tight for the doctor, the chairside assistant can make the call with the doctor only making calls when it is important to talk with the family.

If the doctor is making the calls, do it for just a few patients at first until you get the rhythm of doing it on every patient.

I hope that this helps you to improve your patient communications so that they and you can get the most out of their visits and you can better promote your practice.

Do you obtain a "Covid-19 Informed Consent" form all of your patients, whether established or new?  Do you obtain a "Covid-19 Patient Disclosure" on patients before they enter your office for the first time?  Do you obtain a "Covid-19 Patient Disclosure" (or some shorter spoken version) on established patients as they arrive?  If not, maybe this pearl can help.

Remember when you had to make all of those OSHA changes to your office decades ago?  Well, it's back again with the Covid-19 virus, but hopefully it will only be for a short period of time.

You need to protect yourself and your present patients from Covid-19 infection by masking, using PPE and social distancing whenever possible.  You also need to protect yourself and your patients from New Patient Covid-19 infection before they enter your office for the first time.

This can be accomplished by using "Covid-19 Informed Consent" and  "Covid-19 Patient Disclosure" forms.  These forms can be electronic (filled in on line) or mail-in by downloading and printing the forms, filling them out, scanning the filled out form and emailing it to your office.  Obviously, the on-line electronic method is the simplest to use, but requires that your website allow for this. 

If your new patients have not visited your website before they call for a new patient exam, you simply get their email address and send them a link to your website and to the Covid-19 forms they need to fill out electronically.  Or you can simply email them a paper version of the forms, have them fill them out and scan/email them to you.

The key is to inform them and get their disclosures before they enter the office.  If they cannot do either method, you have a problem.  You can snail-mail them the forms and have them fill them out and drop them off or snail-mail them before their appointment—just like the good-old-days before the internet.

For established patients have them fill out the "Covid-19 Informed Consent" at their next appointment or fill it out and email or snailmail it to you.

I hope that this better prepares you do deal with Covid-19 with your new and established patients.

Are you healthy enough to deal with a Covid-19 infection?  Is your immune system up to that task?  If you are not sure, maybe this pearl can help.

The way I understand it, the immune system works in the following manner.  Once we are infected, the immune system recognizes fragments of the pathogen and activates immune system B-cells and T-cells.  The B-cells mark the pathogen by coating it with antibodies that chomp up the pathogen into little pieces, which alerts nearby T-cells to rapidly multiply and engulf the pieces.  Those B-cells and T-cells quickly die off leaving “memory cells” that help recognize and fight off that pathogen in the future.

As we get older the B-cells become weaker at recognizing new pathogens and the T-cells are less effective at helping the B-cells kill the pathogen.  After the age of 20 we stop making new T-cells and keep the existing T-cells alive.  These existing T-cells tend have shorter and shorter bursts of activity and then die off.  This age-related die-off produces fewer memory cells to assist the B-cells with future infections.

Even though Covid-19 can attack anybody at any age, it is more lethal for those over 65 because of their weakened immune system.  The healthier your immune system, at any age, the better your chance to fight Covid-19 or at least lessen its affects, especially in these stressful times—stress weakens the immune system.

All of this is interesting of course, but how do you know whether our immune system is weakened?  It may be as simple as taking "Elderberry Extract with Echinacea" to find out.  If your immune system is weakened it seems to jumpstart it, making you “feel healthier”.  If taking it does nothing, your immune system is probably not too weakened.  But of course, even with a less weakened immune system it doesn’t guarantee that you won’t be severely affected by Covid-19, but every little bit helps.

About 25 years ago I was constantly tired for many months.  I couldn't work at my home-office desk for more than half an hour without needing to take a nap.  Then a client of mine suggested taking "Elderberry Extract with Echinacea".  I took 2 oz after dinner and the remaining 2 ounces the next afternoon after lunch. That day I was so full of energy that I found myself outside repairing the back roof; it was amazing and I haven't had that fatigue problem ever since.  Another story; my sister told me that when she got home from work every day she didn't have the energy to do anything but go to sleep. After taking the elderberry extract she was up and about and hasn't had that fatigue since. There are many stories like this.

The European elderberries known as “Sambucus nigra” are the one most closely tied to your health and healing.  Its history dates back to 400 BC when Hippocrates, the “Father of Medicine,” called it his medicine chest.  In “folk medicine” the elderberry is widely considered one of the world’s most healing plants.  The berries and flowers of elderberry are packed with antioxidants and vitamins can boost your immune system, help tame inflation, lessen stress and help protect your heart.

You can get the elderberry extract in many places, but the one that works best is called Sambucus, which you can get at the following link or elsewhere:

https://www.google.com/search?q=sumbaca+elderberry+extract&ie=utf-8&oe=utf-8&client=firefox-b-1

Make sure that it is Elderberry Extract with echinacea.

See the attached image for what the product looks like.

The suggested dosage on the bottle is for maintenance of your immune system, but it won’t jumpstart it if it is weakened.  I took it as directed: it with no affect.  Then I purchased another bottle and took 2 oz at dinner and 2 oz the next day at lunch with miraculous results.  This is just my experiential opinion of what works for me and others—no guarantees.  It is also easier to swallow if you mix it in a few ounces of water.

I hope that this pearl is of benefit to you in this pandemic.

Are you prepared to reopen your practice once the economy is open?  Are you prepared to deal with Social Distancing laws?  If not, maybe this pearl can help.

The Coronavirus has closed down all of the US dental practices, which should be able to open soon…hopefully!  When opening this year (and possibly into the next) the “new normal” of social distancing will be in affect until an effective CV-19 vaccine is available. 

Patient scheduling must be considered in terms of volumes of patients allowed to congregate.

The FLOW and treatment of patients must be considered, accounting for social distancing in your waiting room and clinic.

The reorganization of your waiting room and clinic areas must also be considered to protect your team and patients...it's like a new OSHA.

If desired, TeleDentistry can be an option for thinning out the daily patient load.

Refer to the attached PDF "The New Normal - Orthodontics with Social Distancing” for all of the details.  And if considering TeleDentistry, see the attached PDF "ADA Policies on TeleDentistry".

I hope that this pearl helps you to move into the near future as effortlessly and safely as possible.

Is your area free from Coronavirus cases?  Have you taken the proper precautions to protect your patients?  Have you taken the proper precautions to protect your team?  If not, maybe this pearl can help.

The Coronavirus infects both animals and people and can cause a wide range of illnesses from the common cold to lung lesions and pneumonia.  It seems to spread easily from person to person, especially in homes, hospitals and other confined spaces such as professional offices. The pathogen can travel through the air, enveloped in tiny respiratory droplets that are produced when a sick person breathes, talks, coughs or sneezes.  Hundreds of thousands of cases exist throughout the world with thousands of deaths.  As of this writing the US has about 4,000 known cases with about 70 deaths.  To slow down the course of this virus, the federal and state governments have declared that gatherings of more than 50 people are illegal; it may become less than 50.  This pandemic is a serious matter and your practice must take certain precautions.

Scheduling:  In the USA human gatherings are limited to 50 or less people.  In other countries there are other limits, but these suggestions still apply.  The maximum 50 count includes both patients and staff, so if you have 5 to 10 staff, you can have 45 to 40 patients at one time.  Most practices see between 30 and 80 patients spread out over an 8-hour day.  The most crowded times are in the early morning and late afternoon.  After reviewing many busy client schedules it seems that between 10 and 20 patients are seen within any one-hour period for a single doctor Tx day and between 15 and 25 on a two-doctor Tx day.  Bottom line, almost all practices meet the less-than-50 gathering criteria.  Should there be more, you might want to thin it out with more weeks between appointments or by expending the afternoon rush over a longer treatment day.

Distancing:  Keeping your staff more than 6 feet from your patients is impossible, but can be safe if you take the proper precautions.  Keeping your chairs more than 6 feet apart is also difficult, but if you have many chairs use every other chair if possible.  Spread out your “on deck” chairs or limit the amount of patients on deck.  Remove some of your reception area chairs and spread the remaining chairs about three feet apart.  Important, do not allow parents/friends of patients to be in the operatory.  For ultimate distancing, have the patient/family wait in their car and call the patient by text/phone when ready to seat him/her in the clinic.

Precautions:  Following all of the usual OSHA guidelines is important to protecting your patients and team from infecting each other.

• Don’t use a handpiece, it spreads saliva many feet from the patient’s mouth and is hard to clean up on floors, walls, vertical surfaces, you, etc.
• Place a breathable napkin/cloth over the patient’s mouth when not working in that open mouth.
• Sterilization of instruments, supplies, etc. is important and is probably under control, but should be checked out.
• Store supplies (archwires, etc.) away from the chair where they can become contaminated.
• Wipe the entire chair, counter, light and keyboard surfaces with disinfectant after every patient.
• Use facemasks (mainly to protect your patients from you spreading the virus) and use protective eyewear.
• Use personal protective clothing (PPC).  Wear uniforms while in the office and change into personal clothing before going home.  Wear disposable protective coveralls if desired and discard them at the end of the day.
• Have ALL staff wear gloves, especially the receptionist and TC.
• Carefully handle any across toe counter payments and put them in a zip-lock envelope to be sprayed before posting later on.

Screening each patient:

• If possible, measure every patient and family member for a fever when they arrive at the office.  Ask everybody if they have had a fever, a dry cough, fatigue and difficulty breathing or shortness of breath within the past two weeks.
• Do the same for your team at the start of the day.
• If not at the door, measure the patient for a fever when they are seated at the chair.  Ask every patient if they have had a fever, a dry cough, fatigue and difficulty breathing or shortness of breath within the past two weeks.
• If there is an obvious problem, call the patient’s MD for a Coronavirus test and maybe call the patient’s parent/spouse.

Do whatever realistically needs to be done in your special situation to protect your team and patients from infection; this might include canceling patients for a few weeks.

Frankly, maybe the ideal solution is to just shut down for 2-3 weeks and get short term funding to deal with staff salaries if needed!

Dealing with a practice Financial Downturn:

This message is directed to practices who have been mandated to close or are voluntarily closing for many weeks and are having a financial setback in cash flow.  If so, consider the following:

Get a 90-day extension on your April 15^th estimated taxes and/or possibly skip/reduce your June quarterly payment if a drop in income.

Have your team members go on unemployment and only pay the difference between their unemployment pay and usual weekly pay.

Loans help spread out the financial burden over many months instead of weeks ("flatten the curve").

Get a loan from your P&PS, 401K, etc. and pay it back over better times.

I hope that this simple advice helps you to get through this pandemic safely.

Do you have situations with guarantors or patients that are difficult to deal with?  Do you have situations with referring dentists that are difficult to deal with?  Do you have situations with staff or associates that are difficult to deal with?  Or do major decisions about your practice seem to take forever?  If so, maybe this pearl can help.

Over the past five decades my clients have asked me countless questions about how to handle perplexing situations in their practices.  After listening to their comments and questioning them to fully understand the situation, I ask them one simple question and wait for their response.  "What is Best for the Patient in this situation?"  This simple question contains the answers to all of their questions by zeroing in on what makes a practice a success or not—how you address your patient's treatment and well-being.

Yes, every situation is unique and must be dealt with individually, but the answer is based on how it will affect the patient—the basis of your practice and your livelihood.  Once you know how your actions might affect the patient you can address your problem by asking yourself that simple question—consider the examples noted below.

Situations with Guarantors:

Most questions asked of me about guarantors deal with past due patients or adjustments on their accounts.

The question asked: “I have a guarantor who has been ignoring all of our efforts to bring their account current—how do I handle it?”

The answer: “How does your decision affect that patient?” 

If the patient is not cooperating—the typical solution is to ask them to either find another orthodontist or just make them look better than when you started, put them in retention and either cancel their account or go after the balance owed you.

But some guarantors are just not very good at handling finances or the breadwinner may have lost his/her job and you end up the bad guy if you delay (very illegal) or stop the patient’s treatment, especially if it is a great patient and you feel sorry for them.  The first step is to ask the patient if he/she wants to continue with treatment—if they don’t, you have your answer.  The more difficult situation is when it is a great patient who wants to complete their treatment.  I have found that most practices finish the patient’s treatment and then go after the guarantor for payment.  It is also a good practice not to start any of that patient’s siblings.  One client’s patient was so grateful for finishing her treatment that she paid off her balance once she had a job—she constantly praised the practice for what they did for her.

No matter what the question, first consider how your action will affect the patient.

Situations with Patients:

Most questions I am asked about patients fall within the realm of the situations below.

The question asked: “I have an uncooperative patient who doesn’t maintain his appliances, shows up late or not at all, except for emergencies—a nightmare—I want to get rid of him, but his parents are supportive and pay on time—what do I do?”

The answer: “How does your actions affect this patient?” 

In most cases that patient wants out of treatment so just debond and retain them and settle for the amount paid thus far.  If the patient wants to complete the treatment make a pact with him/her to cooperate, stick to a realistic debonding date whether the treatment is completed (good cooperation) or not (poor cooperation).

The question asked: “I have a cooperative patient and family whose treatment is going way beyond the estimated time; should I charge them for the extra treatment time?

The answer: “How does that affect that patient?” 

The facts are: the patient/family is just as frustrated with the case as you are, that you might have misdiagnosed the case, and that you think that you should be paid for the extra treatment.  It is best to discuss the biological problem, give them a new estimated treatment time and ask the patient whether they want to stay in treatment or not.  If no, debond and retain them—if yes, only charge them if their treatment goes beyond that newly estimated completion date.

No matter what the question, first consider how your action will affect the patient.

Situations with Referring Dentists:

The most perplexing question I get about referring dentists is when a patient is unhappy with theirs and wants a referral to another.

The question asked: “My patient told me that they don’t like their dentist, will never going back, and want a referral to another one—what do I do?”

The answer: “How does this affect that patient?” 

If your patient isn’t going back then that’s what’s best for them; the best you can do is mediate between them.  If that family dentist is a poor referrer then it is best to just refer the patient to a family dentist that is a good referrer or one that is a “good fit”.  If that dentist is a good referrer it is best to notify them of the situation and ask that dentist to refer the patient to.  If you don’t like their suggestion you need to choose between a possible referral loss and the patient’s well-being.  In that case just refer the patient to a better dentist and tell the referring dentist that it was the patient’s choice.

When dealing with referring dentists the patient is always the focus of the situation, not your referral basis, and all questions can be answered by just saying to yourself “What is best for this patient”. 

Situations with Staff or Associates:

Most questions I am asked about staff or an associate is about their negative attitude or incompetence.  This type of person brings a practice down and typically negatively affects its growth.

The question asked: “I have a staff member who is negative and/or rude and/or incompetent—what can I do about her”

The answer: “How does she affect your patients’ care?” 

You can try to change their attitude, but that rarely works.  Any team member may be fired at any time since you are not a union shop.  If they are excellent at treatment it is difficult to get rid of them, but I’m sure that if you ask your team or patients they want her gone more than you do.  If she has been there a long time one wonders why (a relative, relative of a referring dentist, etc.), but the solution is the same—get rid of her.

When dealing with an associate that is not as great as you thought he/she might be it is much more difficult to resolve the problem.

The question asked: “I have an associate who is negative toward our staff—what can I do about him/her”

The answer: “How does he/she affect your patients’ care?” 

You can try to change their attitude, but if that doesn’t work you need to start looking for a new associate.  If that dentist is not very competent you need to get rid of him/her immediately to protect your patients or have your staff try to compensate for his/her incompetence until replaced.

Major Decisions about Your Practice:

A major decision about your practice may involve a new associate/partner, office location, change in Tx Mechanotherapy, etc.  Major changes require two questions be asked and answered: 1) how will it affect your patients (negative or positively); and, 2) how will NOT making this major change affect your patients.

An obvious major change is a new office, its location, cost, etc.  If the practice is growing and the present office is becoming inadequate, you need to ask yourself; "How will this affect my patients if I stay here and how will affect them if I build a new office?"  A new single office location is important for a new patient pool, but it may be inconvenient for established patients.  Staying in the inadequate location may save you money, but may make treating there intolerable for both your team and patients.  You need to choose what is best for your patients.

Another major change is taking on an associate/partner to share the work and give you more time off.  The first question is "Will this new partner/associate cause problems with the wrong person, lack of Tx control, etc."  The second question is "Will patient care diminish if you don't have an associate/partner sharing the load?"  You need to choose which affects the patients in the most positive manner.

A final major change is making major changes in your Tx Mechanotherapy.  The first question is "Will this new Tx Mechanotherapy cause more problems with patient care than it is worth?"  The second question is "Will not instituting this new Tx Mechanotherapy reduce to quality of care your patients deserve?"  You need to choose which affects the patients in the most positive manner.

I hope that this “question” helps you to answer your questions about dealing with the difficult aspects of running a successful practice.

If you have a perplexing, unique situation that is difficult for you to resolve, ask it using the “request a pearl” link:(http://www.thebioengineeringco.com/administrator/index.php?option=com_support&view=pmessages).

Do you want a complete understanding of YOUR "Genetic Human Personality" and how it affects your personal and professional life?

If so, download the attached PDF file "Genetic Human Personality".

Are you sure that you know what your genetic personality actually is?

Do you have a good, adequate or poor self-image?

If not, download the PDF "Your Personality Self-Analysis" and take the personality test.

Are your percent Initial Payments averaging between 25% and 35%?  Are your Paid-in-Full-up-front cases under control?  Are your additional family member low initial payments under control?  If not, maybe this management pearl can help.

Background:  It is always best to be paid for your services as you provide them; therefore, you don’t owe them and they don’t owe you for past services.  Being paid much more than what you provide is just as bad as being paid much less (past due, low collections).  There are three phases of your services; Initial, Active Tx and Retention and each make up a certain percentage of your total fee.  In the past, it was about 26% Initial (Initial services = Consults/Records/Initial-Appliances), 50% Active tooth movement, and 24% deband/retention.  Today, overall chairtime has shortened for all three phases and their percentages have changed.  Today there are more efficient Records and Consults visits, longer times between appointments and fewer Retention visits (now about 2-3 visits as opposed to 8 to forever visits in the past).

In the past it took about 1,150 minutes to treat a full braces case; today it takes about 750 minutes for a full braces case (aligner full cases are about 450-550 minutes).  Thus in the past, it took about: Initial = 300 min, Active = 550 min and Retn = 300 min.  Today we have: Initial = 200 min, Active = 400 min, and Retn = 150 min.  Thus for a total Tx time of 750 min we have: Initial = 27%, Active = 53%, and Retn = 20%.  Actually, percentage-wise, this is not much different from the past. 

Of course, the number of minutes, and thus the percentage of total treatment time vary from practice to practice and your percentages will be higher or lower than above.  Thus, an average between 25% and 35% of a full fee is still realistic.

Why does this matter?  If you receive too much or too little initial payment it can affect your cash flow significantly.  And any swing in cash flow affects your NET twice as much.  For example, if your net is 50% and you have a 20% change in your collections, you will have a 40% change in your net.  While a net increase is welcomed a net loss is not.  And of course, if your net is only 35%, you will gain or lose 70% of your net for a sustained 20% change in collections—scary!

For example, for a $6,000 fee your initial payment should be about $1,500 to $2,100.  A paid in full (100% initial payment) is $5,700 with the 5% courtesy.  On the other hand initial payments are typically low (0% to 15%) for multiple family members in treatment simultaneously.  But this is acceptable as long as they are balance out by the patients paying in full.  Typically, 60% of patients pay 25% to 35% IP, about 20% PIF and about 20% pay little to nothing.  These percentages will vary widely depending on your practice situation.

So, if 50% of your starts pay in full, then only 30% (not 60%) of starts will pay the usual 25% to 35% and the overall %IP will end up being 45% to 55%.  Thus, you are getting paid up front for work you haven't completed yet, which eventually balances out with the lower monthly payments as treatment is completed; this isn't a problem unless the patient transfers out and you need to pay them back.

The problem with consistently collecting more than you produce is that you are mortgaging your future income and net.  If you receive 20% more in collections than what you produce, you are taking 20% of next year's collections and shifting it into the current year.  And if you mortgaged 20% of your collections you are mortgaging 40-45% of your NET; i.e., you will receive 40-45% less net if your practice experiences a downturn.  Over-collection is not a problem as long as you produce (charges) the same or greater each successive year, but it becomes a significant problem if your practice is long in the tooth and declining.

Possible Solutions:  If your PIF starts are much greater than 20% of starts and you give a 5% courtesy for PIF, then just give a 2-2.5% courtesy—by giving 5% they are getting more of a return on their braces investment then they would get in their average investment.  If you lower the percentage, you will notice a drop in collections and net in that year, but will get back on course next year and will also contribute that 2-5% courtesy amount directly to your net.

If you have the opposite problem, with too many families with multiple children in treatment paying a low initial payment you might want to encourage more PIF starts by offering a 4-5% courtesy on their fee.  They might be able to pay it with investment monies they are getting a low interest on.

I hope that this helps you to balance out your initial payments and have a less episodic net.

Are your lab appliances being ordered properly?  Are they all arriving at the chair on time for the patient’s appointment?  If not, maybe this management pearl can help.

Whether you use an in-house or outside laboratory to make your active auxiliary appliances, plastic aligner appliances and retention appliances, you need a laboratory control system to make sure that they are available at the chair when the patient arrives for their visit.

A laboratory control system requires designated people to make it work.  It can be as simple as one lab tech in a one-office practice or it can be as complicated as involving many people in a multi-office practice using in-house and outside labs.  But no matter what your situation you will need some variation of the “Lab Log” below to control that system (also see the attached Word file for a customizable copy).

To be effective, your lab control system should flow in the following manner:

1)  Ordering the appliance at the chair and scheduling an appointment to have the appliance inserted, while accounting for any extra charges for that appliance.

2)  A system for getting the impressions or scans to the lab

3)  Control of the manufacturing and delivery of the appliance from your own lab or an outside lab

4)  Getting the appliances to the chair on time for the patient’s appointment

We will now apply this chronology to the usual practice situations (doctors and offices), so pick out your situation below and consider how you might utilize that system in your practice.

For a Single-Office, using its in-House Lab:

After taking the impression, scan, etc., (and entering any charges into the computer/etc.), walk it to the lab and log it in: entry #, Patient’s Name, and the Date IN.  Ideally, and if possible, your lab tech should do all of the scans, impressions and insertions to totally control your system.

Remember to schedule the Date DUE, 1-3 days before the appointment date to allow for fabrication.

Enter the Date OUT when you place the appliance in your operatory "in-bin" for the patient’s visit.

For a Single-Office practice using an OUTSIDE Lab:

When using an outside lab for fabrication (whether for specific appliances or ALL appliances), the lab tech (or DA) logs in: the Date IN as the day it is shipped (electronically or by snail-mail) and the Date DUE as the date the outside lab must have the finished appliance back to your practice.  The Date OUT is the date you placed the finished appliance in the operatory in-bin.

Multi-office, especially with multiple doctors, practices are more complicated than a single office practice.  The main difference is that the scans, IMP, etc., should be brought to the main office to be processed and the finished appliances should be brought from the main office to the branch office and stored for the patient’s scheduled visit.  It physically requires that each branch office have a: lab log, out-bin (to hold IMP, etc., until transferred to the main office) and an in-bin (to store appliances ready to be inserted).  The system is simpler for a multi-office one-doctor practice with just one clinical team then it is for a multi-office multi-doctor practice using multiple clinical teams.  It is best if each branch office has a specific DA in charge of all labwork to and from that office.

For a One-Doctor, Multi-Office practice using an in-House Lab:

In a one-doctor practice it is best, if practical, to have one DA (who goes to every office) responsible for controlling the system in that office.  You will also need a separate Lab Log in each branch office for control.  When processing a patient’s appliance, the branch office Lab Log's Date IN is the day the IMP, etc., was taken back to the main office and the Date DUE is the date the finished appliance needs to be back in the branch office in-bin.

Schedule the appliance insertion appointment far enough ahead of the branch office Lab Log Date DUE to have enough time to fabricate it and transfer it to the branch office in-bin.

The branch office lab log Date OUT is entered when the finished appliance is placed in the branch office in-bin.

For a Multi-Doctor, Multi-Office practice using an in-House Lab:

As much as possible, have a designated DA responsible for controlling all labwork to and from each branch office.  Use the branch office Lab Log for control: using the Date IN as the day the IMP, etc., was taken back to the main office and the Date DUE as the date the appliance needs to be back in the branch office in-bin.

Schedule the appliance insertion appointment far enough ahead of the branch office Lab Log Date DUE to have enough time to fabricate it and get it back to the branch office in-bin.

The Date OUT is when the appliance is placed in the branch office in-bin.

For ANY Multi-Office practice using any OUTSIDE Lab:

Process the scan, IMP, etc., the same as above (to get it to and from the main and branch offices). 

The lab tech (or designated DA) in the MAIN office logs the scan/IMP Date IN as the day it is shipped (electronically or by snail-mail) to the outside lab and the Date DUE as the date the outside lab must have the finished appliance back to you.  The Date OUT is the date you place the finished appliance in your main office in-bin OR the date you sent it to the branch office.

If it is going to the branch office, enter the Date OUT in the branch office Lab Log when placing the appliance in the branch office in-bin.

I hope that this helps you to better control your labwork and get every one of them to the chair on time the patient’s appointment.