Are you an orthodontist committed to giving your patients beautiful smiles and perfect function, or are you a shill for appliance manufacturers that mightily try to convince you that only their aligners, their brackets, their wires, or their ultra-sonic device will give you the finest clinical result in the shortest possible treatment time?  Judging from the “Messages on Hold” I hear frequently, too many doctors are the latter.  Promoting a brand name clinical appliance to patients placed on hold, in the belief that patients actually care what brand appliance you use, is wasted effort.  Betty says that doctors are forgetting that they, and not their appliances, are the “magic” that creates great case acceptance.

For almost 34 years now I have been consulting with orthodontists and back in 1980 when I started, case acceptance percentages were better than they are today!  Those who would tell you that the problem is the economy, the competition, the high fees, the shoppers, etc., are looking for an excuse that allows blame to fall on an outside and uncontrollable issue, so they do not have to look too closely at what is actually going on inside the practice that is virtually always the true cause of case acceptance problems.

From 1980 to 2000, average case acceptance rates in the U.S. rose more or less steadily.  The total increase was miniscule, from about 62% to 64% over those 20 years, but it was an increase.  Since 2000 the rate of case acceptance has declined and is now back to roughly 61%.  What’s happened?  As I said, many doctors want to blame performance problems on something beyond their control, something like the bad economy.  While it is true the economy went deeply south starting in 2008, the decline in case acceptance had started eight years earlier!  In fact, the economic decline caused new patient flow to decline while case acceptance percentages in 2008 and 2009 actually went up!  What happened is that new products, often very expensive products that significantly decrease treatment time, have come onto the scene since 2000.  The problem with case acceptance is incredibly simple.  The profession has priced itself right out of the middle class marketplace!  Short treatment times and the resulting high payments required, much more than the case fee, have brought case acceptance rates down.

The responsibility of any entrepreneur – that’s you! – is to make it easy for the customer to buy what you sell.  Just the exact opposite has been happening now for 13 years.  Consider what has become a typical situation.  An orthodontist starts using clear aligners or robot built wires or brackets, or other technology with high overhead and short treatment time.  The orthodontist typically raises fees somewhat to account for at least part of the cost of those appliances, and the Treatment Coordinator then quotes a 12, 16, or 18 month treatment time and a monthly payment that is often more than double what the payment would be if traditional appliances and traditional treatment times would have been quoted.  As the patient/parent walks out the door, you can hear the plaintive pleas from the doctor…“But these are state of the art!  The fact I use them proves I am the best orthodontist in town!”  But, the patient is often running into the arms of another orthodontist!

Only 20% of patients coming to an orthodontist have short treatment time as their primary motive for seeking treatment.  About 5% of exams are simply price shoppers and are seeking treatment from anyone who has the lowest case fee.  Most of the remaining 75% are looking for a quality experience and a monthly payment they can afford.

One of our clients said to me a short time ago, “Less treatment time and fewer appointments should mean less overhead, yet my overhead is off the charts high.”  My response to him was, “Of course your overhead is ‘off the charts’ high!”  I have heard that complaint from every single one of my clients using short treatment time technology, as have most of the case acceptance and other Practice Management consultants in the country.  These high dollar, short treatment time appliance manufacturers, have been trying to sell that “reduced overhead” bill of goods to doctors since the first such product came on the scene in 2000.  Even some seminar leaders are preaching that “reduced treatment time and fewer patient visits means more revenue per visit, less overhead, and greater profit.”  Some doctors have drunk so much of this Kool-Aid that they have cut back on Phase I treatment in order to cut the number of overall patient visits and increase revenue per visit.  The resulting huge decline in case acceptance (Phase I cases typically have 85%-95% case acceptance!) and resulting decline in patient retention from recall has caused drastic declines in the profitability of many orthodontists.  The bottom line is that all of the talk about reduced patient visits creating lower overhead and greater profit is hogwash if you cannot sell enough of those cases to cover the fixed practice overhead along with the very high lab fees associated with these appliances.  I often ask, “What check do you not write because you can now treat patients in 16 months instead of 20 to 24 months?”

That same client said, “Faster treatment and better results should mean better acceptance, but my case acceptance has declined!”

Again, “of course!”  Although all patients appreciate short treatment time, only a very small percentage of patients have faster treatment time as a primary requirement.  The vast majority want affordability!!!  “Better clinical results” is only a useful argument with the small percentage of people that you can convince that your finished cases are significantly better than the competition, which means of course that those results are significantly better than you yourself obtained prior to using your new technology.  If that is the case, it must mean that you obtained only mediocre clinical results in the past!  That’s mute anyway because your patients believe that because of the credentials on the wall, you are fully competent at straightening teeth, providing perfect function, and making beautiful smiles.  Trying to get patients to believe that your particular choice of appliance is significantly better than the competition and to be willing to pay a great deal more per month for that better treatment is like trying to teach a pig to sing.  It’s unsuccessful and it annoys the pig!

The fundamental theory that fewer patient visits reduces overhead is only true if, because of fewer patient visits, you can put more new starts into the schedule and if you have raised your fees enough to cover the extra overhead associated with the appliance being used.  In fact, while most orthodontists may have room in their schedule for more starts, the vast majority do not have sufficient new patient flow and/or sufficient case acceptance rates to be able to add more starts than they already have.  So, there is less net revenue because of greater lab fees and fewer case starts because of the short treatment times.  That is the reason why so many doctors have gone back to more traditional treatment and appliances.  They have decided to make it easy for their patients to buy the product they sell!

There is another problem associated with this high dollar and reduced treatment time issue.  As mentioned, the reduced treatment time makes payments unaffordable to large numbers of patients, who then go elsewhere, and communicate back to their dentists that you were “too expensive.”  New patient flow declines are not uncommon in this situation.  Again, far more patients are payment sensitive than are fee sensitive.  If the patient/parent cannot afford the payments, you are “expensive” no matter what your fee may be.

Is there a place in the profession for the new technology and short treatment time?  Of course!  Should you be using that technology?  Again, of course!  The shorter treatment time will generate some starts that you would otherwise never have.  The problem is not the technology.  The problem is that only a relatively small percentage of patients can afford that technology and abandoning more traditional forms of treatment and making this new technology your exclusive “standard of care” is a huge economic mistake.

“Socialism is a philosophy of failure, the creed of ignorance, and the gospel of envy; its inherent virtue is the equal sharing of misery.” —Winston Churchill