The Bio-Engineering Co.

Are you getting 7-8 hours of sleep/day?  Do you wake up many times while sleeping?  Do you lie awake in bed for hours during the night?  Maybe this pearl can help you get a better night’s sleep.

Let's face it, if you are in pain or anxious about anything you will not get a restful night's sleep.  But, other than that you can get a more restful sleep if you can find the variables surrounding sleep that work for you.

Research has shown that it is healthy to get about eight hours of sleep a night; unfortunately this is not usually the case, especially if you are over 50.  If for example, you went to bed at 10:00 pm and awoke at 6:00 am that may constitute eight hours of sleep, but it usually does not.  Most people who “sleep” for eight hours end up only getting about 6 to 6.5 hours of actual sleep.  Even people who “sleep” for 9 or 10 hours only get about 6.5 to 7 hours of sleep; and lets face it, who can afford to lie in bed for 9 to 10 hours unless they are retired from work.

Most people have to be up at a certain time each morning and thus, if you go to bed an hour earlier you might get that important extra hour of sleep.  For most people, lifetime habits keep them from going to bed earlier, but that can be change for at least a few days a week if not every day.  If you think about going to bed an hour earlier instead of thinking about doing the usual, TV, reading, work, etc., then you will get to bed earlier.

But, just going to bed an hour earlier doesn’t guarantee an extra hour of sleep.  I have found that I just lie in bed an hour longer before going to sleep.  Something else needs to be changed.  We need to relax our body before going to sleep so that the muscles we abused by excessive sitting/standing/bending all day are relaxed.  Doing exercises that stretch the back of your legs works just fine.  If you want an even better daily exercise regimen (and have a healthier less painful back), click on this link.

Research has also suggested that late night snacking can affect our sleep.  Supposedly, having carbohydrates (sweets) puts us to sleep and protein foods keep us awake.  Personally, I find that if I snack 2-3 hours before bedtime that it disturbs my sleep.

Research has also suggested that if you keep the room below 70° (preferably 68°) that we will sleep better.  I find that if the room doesn't have a little chill that I can't fall asleep.  Unfortunately, that chill comes with more of a need to visit the bathroom.

Some people find that they can’t sleep if there is too much light in the room—so keep the room dark.  Some people find that ambient noises interfere with their sleep and therefore use a fan, air purifier or sound box to drown them out.  A snoring bedmate can also destroy a good night’s sleep—I find that my hours of actual undisturbed sleep is increased significantly using soft rubber ear plugs (like you get on a plane redeye flight) to quiet the snoring.

But even going to bed earlier, stretching and masking light and sounds may not guarantee you a good nights sleep; you may still lay awake for hours with intermittent sleep.  If that is the case, you may need to help your body/mind to allow you to sleep—I find that melatonin helps.  Melatonin as you know is secreted by the pineal gland when your eyes detect sustained darkness.  Melatonin blocks off your body sensations from the neck down allowing you to go into a deep sleep.

Every person reacts differently to melatonin supplements, but you can eventually find what works for you.  For the past 10 years I have averaged 6.4 hrs/night of actual sleep, while lying in bed for about 8-9 hours.  For the past five months I have experimented with melatonin with dosages of 9 mg/night, 6 mg/night and finally 3 mg/night and averaged about 7.3 hrs/night sleep while in bed for 8+ hours (big improvement).  I decided on 3mg/night because 6 or 9 mg/night made me feel a little sluggish the next day and because too much melatonin will eventually stimulate seratonin that tends keeps one awake.

Now that most of the usual variables surrounding a good night's sleep have been presented, maybe you can find the mix that helps you to get a more restful night’s sleep.

Does your net usually fall within 35% and 55% of your collections?  Are your charge adjustments/courtesies greater than 3% of your fees?  Are some of your “expenses” actually part of your net?  Do you have a monthly budget?  If not, maybe this management pearl can help.

In the previous management pearl we discussed how to maximize your collections.  In this pearl we will discuss how to keep as much of those collections as possible by controlling your expenses.

The fact is, if your net is less than 40% of collection that your expenses will not be under control unless you have a realistic monthly budget.  And if your net is under 30% you absolutely need a realistic monthly budget and have someone other than the doctor in control of it.

I have been keeping track of my clients’ production, collections and net income for decades and one fact is evident: practices that have a realistic monthly budget to keep track of their expenses better control them and usually have a higher net.  But the net is predicated on the personality of the doctor and how he/she runs the practice.  Strong socializers tend to “give away the store” while the opposite personality, strong analyzers, tend to tightly control their expenses.  But even strong socializers can benefit from a monthly budget if they pay attention to it.  Athought that may be sobering: every time you give a patient a $1,000 courtesy you lose $1,000 of your net.

Expenses vary from practice to practice; so instead of talking about budgets, lets talk about realistic expense percentages (the year-to-date expense category’s amount divided by the year-to-date collections amount).  The expense categories are:  Salary-Related, Team P&PS, Occupancy, Utilities/Telephone, Clinical Supplies, Laboratory, Clerical Expense, Practice Promo/AD, Purchased Services, Miscellaneous, and Patient Refunds.

See the two attached PDFs for a much fuller explanation of these categories and how you can keep them from getting out of control. 

Do your collections accurately represent your adjusted production?  Is your bookkeeper collecting everything charged?  Are your past due accounts minimal?  Are your Credit Card, Direct Deposits and Insurance payments under control?  If not, maybe this management pearl can help. 

Once your starts and miscellaneous charges are properly posted, you need to collect all of them.  Unlike charges, which are instant the day they are posted, collections are posted over many months or years and require more control.

The factors that affect an increase or decrease in monthly collections, in order of probability are:

1)  A significant change in the amount of the initial payments collected

monthly payments

2)  Insurance payment changes that can get out of control

3)  A sudden change in past due accounts do to economic conditions or poor past due control.

4)  A sudden change the typical monthly payment amounts

5)  Embezzlement of practice collections and lack of daily cash control

Factors to make sure that your collections are under control include:

1)  Collect the initial payment on the IP date; and if not follow it up

2)  Having only the bookkeeper post charges and payments (note about many adjustments in practices that don’t).

3)  Controlling the daily collections; accounted for by more than one person

4)  Control of contract adjustments: are those adjustment categories understandable?  Are the contract adjustments monitored weekly/monthly and if so by whom?

5)  Is the bookkeeper billing and going after the miscellaneous charges?

6)  If the unknown drop in collections can’t be accounted for, is it embezzlement?

Refer to the attached PDF for a better understanding of why your collections change.

Is your production optimum for your services?  Is your TC setting your fees and financial agreements correctly?  Are your contracts accurately set up on your computer and followed up?  Is your financial coordinator a part of your financial agreement control?  Are your miscellaneous charges getting posted?  If not, maybe this pearl can help.

In the complex world of orthodontic charging, billing, collections and expenses many clients find themselves asking, “Where’s the money?”  Sometimes it seems that charges (production) is too low, or that collections are not keeping up with production, or that the net seems much lower than it should be.  Typically, this can be resolved with a few calculations, but sometimes there are many complicating factors.  It is the purpose of this three-part pearl to better understand “where the money is”.  

PRODUCTION: The factors that cause a decrease in production, other than fewer starts, are in order of probability:

1)  A large increase in fee courtesies/deals to get them started

2)  A sudden drop in Ph-I/Lim or Invisalign starts in a practice, which does many of them

3)  A sudden drop in fees due to less treatment required per start (12 months vs. 24 months, etc.)

4)  Poor control of fees and financial agreements

5)  A sudden acceptance of Preferred Provider insurance starts that reduce your fees by up to 25%.

Staffing factors that affect your charges include:

1)  Who sets the fee: the doctor or is it automatic, based on the treatment required?

2)  Is there a Fee Schedule and set of possible financial agreements for every treatment fee listed?

3)  Who determines the discounts and courtesies (doctor or TC)?

4)  Who negotiates the financial agreement and sets the initial payment (TC)?

5)  Who enters the contract into the computer (TC or Financial Coordinator)?

6)  Is every treatment fee and financial agreement contract that is entered, monitored by a second person (doctor, Clerical Coordinator, TC, Financial Coordinator, etc.)

7)  Who sets the non-contract (miscellaneous) fees and who posts and collects them

Refer to the attached PDF for more guidelines on “where the production went”.

This concludes how production affects where the money went; the next part will analyze "where the collections went".

Is your practice productive and are your team members busy?  Do you know how to keep them busy when the doctor is not in the office?  Do you have a contingency plan for when you will be out of the office for an extended period of time?  If so, this management pearl may help.

Running a successful practice is not easy, especially when it comes to keeping your team productive or busy.  Practice-wise, staff account for about 20-30% of your overhead and it is a shame to waste it.  Team-wise, staff should not be hectic or board, but instead, have a smooth, productive day.  The best way to accomplish this is to have a well-designed schedule that utilizes your team effectively and to conduct your days so that you can adjust to the ups and downs effectively.  Refer to the following if you want to design a smooth productive schedule:  http://www.thebioengineeringco.com/index.php?option=com_hikashop&ctrl=product&task=show&cid=47&name=schedule-design-tx-quality-control-kit&Itemid=860

Other than scheduling, most practices have on-going weekly procedures to cover the office when the doctor is not there.  This typically involves a receptionist to cover the phones and a DA to deal with emergencies.  The DA can be scheduled in the office or be on call for emergencies; whatever works.
 
There are also certain situations arise that can upset both you and your team—when the doctor is not in the office and team members are.  The doctor may be away on vacation or fall ill and need to be out of the practice for weeks or months.  During his/her absence the doctor doesn’t want to waste money on office coverage when patients are not being seen.  Some team members do not have the financial discretion to not work and may not have the vacation time to cover the doctor’s absence.  This causes conflict between the doctor and team members that needs to be resolved.  There is usually an unwritten agreement between the practice team members that they will receive their usual pay.  But that all falls apart when the doctor will be out due to long-term illness.

If the illness strikes quickly and the doctor can’t treat patients for many months, the practice can run down hill quickly.  That’s why it is important to have a realistic “overage agreement” between your practice and others.  It may involve other local orthodontists or friends at a realistic distance.  If you don’t have an up to date coverage agreement you need to get one.  The AAO website and others have agreements to refer to, to set up your coverage.
 

When the doctor is scheduled to be out for weeks for a medical emergency or whatever, it is unfair to have needy team members bear the unforeseen financial burden of not being able to work and get paid.  If planned far enough ahead, the practice can have another orthodontist treat its patients according to a specific schedule.  If this is not possible, you can give team members who have to work specific projects to complete by the time the doctor gets back.  Such projects may include:

1)  Clinical: clean, restock, reorganize and restock all of the supplies closets/areas

2)  Clinical: clean, restock, reorganize and restock all of the supplies closets/areasClinical: do a thorough cleaning/maintenance of the sterilization area, records area, any Tx chairs/units, etc.

3)  Clinical: bring in patients with hygiene problems and spend the time teaching them to do better (tell them you are having a special hygiene clinic for them)

4)  Match payment files with active patients to make sure that every patient started has a financial agreement

5)  Do a thorough study of your patients with insurance and make sure all filings and payments are up to date

6)  Go after all of those Will-Call-Back patients and get them scheduled

7)  Print out a list of all patients on OBS-Recall (and Ph-I retention) and make sure they all have appointments; if not make them

8)  Do a thorough study of your patients with insurance and make sure all filings and payments are up to date

9)  Do those special projects (marketing, etc.) you have been putting off until you had the time

10) It is helpful to keep an ongoing list of projects you need to get done in situations like this

The practice will need to monitor the team member's project progress by checking up on them daily (or the days they are scheduled to work) to see how well they are doing and whether they have any questions.  Nothing is perfect, but planning ahead helps.

At least four percent of the US population gets gout attacks (about 12 million).

Unfortunately, they also get useless advice on how to deal with gout attacks.

If you or anybody you know has a problem with gout attacks, this pearl is helpful.

Go to the following link for help or Email this link to family and friends with gout.

Do you have difficulty resolving conflict with your team?  Do you have difficulty resolving conflict with your patients?  Do you have difficulty resolving conflict in general?  Maybe this pearl can help.

In every situation you have a goal for being involved; otherwise, why are you involved?  Sometimes problems—that must be resolved—get in the way of attaining that goal.  The best way to resolve a problem is to look at the various solutions, consider the pros & cons of each solution and then choose the best (although not perfect) one to best attain that goal.  For example, a patient is supposed to pay for the treatment they receive—if they don’t pay there’s a problem.  The solution may be to contact them and 1) obtain the payment in full; 2) refinance their account; or 3) finish their treatment and sue them.  There are pros & cons to each solution and depending on the patient, one solution is chosen that is agreeable to both the practice and the guarantor (except maybe solution 3).

But some problems are difficult to resolve because emotions flare up and rational thinking takes a back seat—this is where conflict arises.  For example, your financial coordinator may be upset because she has been trying to get in touch with the guarantor who avoids her or who agrees to make payments that are not made.  Or the patient/guarantor may be upset because the treatment is not going as well as they feel it should and feel ignored or unheard—we all need to be heard.

To be heard, we have to also listen, which is not easy to do during a conflict situation.  When listening, it is probably best if you are the first to do the listening:

1)  Look at that person’s eyes and intently listen to what he or she is saying; don’t look away

2)  Ignore every thought that comes to mind and re-focus on what he/she is saying

3)  Do this as long as they speak and don’t even think about responding

4)  When they obviously stop speaking (usually after repeating themselves) they will stop

5)  Since you intently heard them out, they will now listen to what you have to say

Unfortunately, rational listening is impossible when we are angry, which shuts off our rational brain.  And when angry, we only use our director style, which motivates us to believe: "only my opinions are valid, not yours", and; "only my concerns matter, not yours".  This makes it impossible to listen to the other person since what they have to say is irrelevant.  Anger can elevate into rage, especially when the conflict is between family members, causing a screaming match and statements we later wish we had never said.  To get past this anger/rage we need to:

1)  Realize that we are emotionally out of control (the screaming is a good indicator)

2)  Stop thinking and take 2 or 3 deep breaths to allow the anger to subside

3)  Realize that we are hurting someone we care about

4)  Apologize for being angry and hope the other person does too

5)  Restart the discussion with a problem-solving, win-win attitude

6)  When done give each other a big hug—allow yourself to enjoy your oxytocin rush and feel love

Once you have taken the emotion out of the situation and each have been heard, you can approach it as a problem-solving situation by considering specific solutions with their pros and cons and mutually choose the best solution.  The chosen solution must involve compromise by both parties or else emotions will flare up again and turn a problem-solving situation into another conflict resolution situation—so be careful.

When dealing with patients don’t forget that the treatment needs of the patient (not the family, guarantor or practice) are paramount in every situation—you will probably need to compromise more than they do to do what is best for the patient.

When resolving conflict with your team, family members or anyone important to you, use the same approach of LISTENING INTENTLY to them, then giving your side, then looking at the possible solutions with their pros and cons and finally compromising.  Try it, you'll love it!

Do you experience the healthy, wonderful feeling of love daily?  Or does your fear, anger or opinions get in the way?  Would you like to experience more love each day?  If so, maybe this pearl can help.

There are as many definitions of “love” as there are people to define it—but definitions of love are not as important as the feeling of love, which comes from our emotional energy.  The fact is, we transmit and receive emotional energy to and from others, which is either negative (from our fear and anger) or positive (from our joy).  Joy is the instantaneous adrenalin rush we feel in our heart when we physically recognized (see, hear, etc.) a connection (family, friends, pets, possessions, etc.)—and, the closer we are to that connection the greater our joy and positive emotional energy.

Unfortunately, the positive emotional energy we transmit is not necessarily received.  There are two types of love: one-way love (our positive emotional energy is transmitted, but not received) and two-way love (we simultaneously transmit and receive it from others).  As wonderful as the feeling is for us transmitting our one-way love, it is not necessarily the same for the other person no matter how much we truly believe in and say, “I love you”—resulting in the usual response, “I love you, too”.  The other person’s “I love you, too” response can also be an expression of their love for us, but we don’t feel it from them because we are not receiving it.  Joy is a one-way expression of the love we feel from an adrenalin rush in our heart.  Bonding is another one-way expression of the love we feel from an oxytocin rush in our brain; again, the positive emotional energy from bonding is transmitted but not received.

In two-way love, ours and the other person’s positive emotional energy are transmitted and received simultaneously amplifying the oxytocin rush—it is quite wonderful.  This is how we can tell the difference between one-way love and two-way love; two-way love is a much more intense feeling of love.  So, how can you experience more two-way love daily?

1) By sustaining an impromptu oxytocin rush (bonding).

2) By purposefully bonding with others, thus causing an impromptu oxytocin rush.

Impromptu bonding occurs when you and another person simultaneously have the same positive thought.  You know what I mean; he/she says something just as you were about to say it, automatically bonding you and releasing oxytocin into both of your brains.  It is a wonderful moment that is instantly dissipated as less positive opinions quickly enter your minds.  But with practice you can learn to dwell on that positive moment by ignoring your contrary opinions or "instantly agree" (see below).  But as wonderful as this is, it is difficult to count on sporadic impromptu bonding for your daily dosage of love—this is where purposeful bonding comes in.

Purposefully bonding requires that you become a part of the moment, especially when it involves a topic that you have contrary opinions about.  If you try to see their point of view or to dwell on the positive aspects (that which you agree with) of their discussion, you can purposefully bond with them.  At first this is mostly one-way bonding—which is better than nothing.  Fortunately, this allows you to feel more comfortable with their point of view, which can lead to impromptu bonding, since you are both talking about the same kinds of things and your thoughts will simultaneously overlap.

You can also create purposeful bonding by genuinely, "instantly agreeing" with someone's statement.  Just allow yourself to see something positive about their statement—nothing negative—at first, it is difficult to do, but eventually it creates a positive state of mind that promotes impromptu bonding.  It also allows others to feel more comfortable with you, since you instantly agree with them, opening them up to instantly agreeing with you and allowing for even more impromptu bonding.

The more positive you are about the opinions held by others in your life, the more opportunities you will have to share two-way love.  If you have too many differing opinions with them, you need to dwell on the positive aspects of their statement and don't let your contrary opinions enter your mind.  This is difficult for fault-finding analyzers and directors, but it can be done; I’m proof of that.  And the more you relax your contrary opinions and value their opinions the easier it will be to accept their opinions (but not necessarily change yours), allowing for more loving/bonding moments.  And a funny thing happens in time when you give their opinions value; it allows you to be open-minded enough to actually see their point of view—which can be opinion-changing—and your reward is more and more loving/bonding moments in your day.  It also allows them to be more open-minded about your opinions.

In the past, my contrary opinions would automatically destroy my loving/bonding moments, but not so much any more, making me feel more two-way love for my wife, children and friends than I have ever felt before—I only wish I had learned this sooner.

If you want to learn more about your interactions with others, refer to "Personality Finesse...how we nurture our nature".

Do you have many run-on patients?  Are some of your appointment intervals greater than 10 weeks?  Do you like to try new Tx Mechanotherapies?  If so, dental monitoring might help…maybe not.

Dental Monitoring is a new way to keep track of your patient’s treatment.  In general, keeping track of most patients is part of your service, but sometimes that can get out of control.  If your appointment intervals are 10 or more weeks, patients can get lost or their treatment may go off course due to non-cooperation, misdiagnosis, or damaged braces.  If a patient reschedules many times or misses many appointments, they can easily become run-on patients, with or without long appointment intervals.  Dental Monitoring can be used for both Braces and Aligner Treatment Mechanotherapies.

See the attached PDF “Pros & Cons of Dental Monitoring” for more insight.  Also see the attached PDF “Dental Monitoring Costs” for a better understanding of its financial impact on your practice and how you might handle it.

Do your Emergencies just show up, or do they call first?  Do you have a means of determining what kind of appointment to bring them in for?  Do you have problems finding an appointment for them?  Maybe this pearl can help you reduce the frustration of emergencies.

There are numerous types of emergencies requiring more or less chairtime and doctor time.  It is foolish to waste chairtime and doctor time if not necessary.  It is also important to plan for inevitable emergencies.  Typical emergencies and the types of appointments they need are:

10-15-minute Emergencies: Poking Archwire, Poking Ligature wire, Ligature Chain off, Separator out, Loose Archwire, Elastics concerns

20-30-minute Emergencies: a Loose Bracket, a Loose Band, Broken Archwire, Broken Appliance, Severe Trauma/Pain, Parent/Patient upsets

40-60-minute Emergencies: Multiple arch breakages or a selfie that shows the need for more chairtime

You must train your patient/families to call when they have an emergency.  You can’t plan if they just show up and wreck your daily schedule.  When they call, they need to provide the receptionist with enough information to be able to schedule the required appointment to resolve their emergency.

An “Emergency Card” reference (see attached Word^® file) is helpful to pick out their problem.  It is also helpful to have the means by which they can text the receptionist a selfie of their problem so that she can determine what kind of appointment to schedule.  To make your Emergency Card, just enter your office and phone number, email a pdf of the 4.25" x 5.5" card to your printer, print on gloss card stock about 1,000+ for each office and hand them out to your patients.

For this system to work you need “hold” appointments in your schedule.  These are 1, 2 and 3-unit appointments (e.g., 1-Hold, 2-Hold, 3-Hold) in your schedule that are not scheduled until the afternoon before or the day of those hold appointments.

The combination of patient training, Hold appointments and Emergency Card should help to reduce the frustration and waste of your emergency appointments.  Also refer to the pearl http://www.thebioengineeringco.com/index.php?option=com_k2&view=item&id=241&Itemid=766  for more information on emergency patient control.

See the attached Word® file to create your customized Emergency Card.