Orthodontic practices may use a variety of tools and assessments to address the question of whether they are consistently reaching their full potential for profitability. While determining the best approach for an individual practice is a complex decision, two practices profiled in this issue of the Practice Management Bulletin offer interesting examples of how to incorporate profitability management into practice operations.
The practices use data analytics and a systems/team communication approach, respectively, to help ensure that profitability remains consistent. While the methods are somewhat different, both practice founders set efficiency and profitability evaluation as priorities early in their careers – and as a result, have maximized their success over the long-term.
Both practices have also closely monitored and worked to address two key obstacles to profitability that impact many orthodontic practices: emergency and repair visits and situations in which treatment is not finished by the patient’s estimated completion date.
Sustain and Build Profitability with Effective Systems and Accountability
When Dr. Sami Webb completed the orthodontic residency program at The Ohio State University in 2004, she and her husband, optometrist Dr. Jason Webb, hoped to settle in a rural area.
Dr. Webb planned to open an orthodontic practice and become very active in the local community. The Webbs identified Kalispell, Montana as their destination.
“As I began the process of trying to open a practice in Montana, it quickly became apparent that the banks at that time were not lending money easily,” says Dr. Webb. “The financial issues became a major problem. Then, I had an opportunity to purchase a very small satellite practice in Scottsbluff, Nebraska that was located in a hospital and only open on Mondays. The selling doctor worked with me for just four days, so the transition was extremely short. I basically had to operate as a start-up and figure things out on my own.”
The Webbs decided to stay in Nebraska, which was closer to their families in South Dakota. Dr. Webb’s goal was to build her practice into a full-time operation – but she found she reached her goal much more quickly than expected. Within a year, she opened a satellite office in Alliance, Nebraska and built a new office for the Scottsbluff location. Two years later, she built a new office for the Alliance satellite.
“I never imagined we would grow as quickly as we did,” says Dr. Webb. “All my energy went into patient care, scheduling, hiring and training new staff, new office locations, etc. I wasn’t focusing on the business and never had the chance to learn from the doctor who sold me the Scottsbluff practice. I was just getting by and not paying attention to profitability. Fees were low, no goals were in place, and we had no systems in place. I began thinking about one of my faculty members in residency who told us, ‘When you have your own practice you need to work with a consultant. If you hire one and your practice does not benefit, I’ll pay for it.’
“That certainly made an impression on me!” Dr. Webb continues. “As I considered hiring a consultant, I decided that Char Eash would be a good fit for us because she brought a lot of experience working with rural practices, and I liked her emphasis on systems development within the practice to increase efficiency and profitability. I was always striving for efficiency and wanted expert help with building systems.”
Process Improvements Helped Make Possible Further Expansion
In 2009, guided by Ms. Eash, Dr. Webb’s practice overhauled scheduling and developed goals for multiple practice metrics. Dr. Webb began reviewing profitability consistently. Making these changes helped the practice become more efficient before its next round of expansion: the 2010 opening of a satellite office in Crawford, Nebraska (moved to Chadron, Nebraska in 2014).
“We had a spike in profitability from 2009-10,” says Dr. Webb. “Char’s production calendar and scheduling for success has probably been the most important tool we have implemented that has helped lead to profitability. The calendar forces us to look at production each day to ensure we reach our yearly goals. We also look ahead at holidays, days off school, etc. to make sure we plan for an increase in production on these days and utilize our time properly. We try to schedule our longer appointments such as bonding and debonding during the slower parts of the day. We try to reserve our time before and after school for our adjustments to give as many people those appointment times.”
While using doctor and staff time efficiently is a key to profitability for the practice, the practice also strives to help patients from a time-efficiency standpoint.
“Practicing in a rural setting means that it is common for patients to drive for an hour or more to get to us,” says Dr. Webb. “We do a lot of same-day treatment starts following exams, and plan for that by gaining as much information from our new patient calls as we can. Patients are coded to fit into certain exam appointments. If they are definitely ready to begin treatment following their exam, we will have a time slot in the schedule for bonding so they don’t have to make an additional trip to get their braces. We also fabricate many appliances in-house, including expanders, within about 45 minutes, so when needed those appliances can be ready for patients almost immediately.”
Accountability, Debond Analysis Help Maintain Profitability
The practice continues to work with Char Eash, who returns every year or two to review the practice systems.
“We tend to get caught up in our own world of patient care and it can be easy for our processes and systems to slip,” says Dr. Webb. “Through team leadership we try to hold ourselves accountable to each other for consistency in maintaining our systems, but it also helps to know that we are going to be accountable to Char.
“Our leadership team, made up of myself, our scheduling coordinator, the office coordinator, the financial coordinator, the clinical coordinator, and our treatment coordinators, meets monthly,” adds Dr. Webb. “Each individual is expected to gather statistics, analyze the statistics, help correct problem situations, etc. We dive into the financials of the practice, set goals, look at conversion rates, collections, referrals, call backs, marketing, etc. We also delve into patient status counts, making sure that each patient’s status is noted correctly, and we follow a purge protocol to ensure we no longer have patients in our system who do not need to be there. This review also spurs us to address whether a patient’s treatment may need to be discontinued because of lack of progress due to poor patient compliance.”
The practice has been tracking debonds for almost 15 years now, reviewing every patient after their braces come off and
doing an analysis.
“In the debond analysis we look at profit per visit,” says Dr. Webb. “We review the total fee minus any discounts, if applicable; the number of regular visits; and the number of emergency visits. Then we calculate the final fee per visit to see if it meets our target fee per visit. We can also see what our average treatment times are, if we are close to estimated treatment time for the patient, etc. Looking at these data ensure that we are working on efficiency and achieving profitability.”
The leadership team also conducts status counts, tracking the number of patients in active status, new patients, recalls, retention, etc.
“We look at these numbers in all of our locations and compare them to previous years,” says Dr. Webb. “This gives us an idea of where we are gaining, losing, how it compares to previous years, which satellites are growing or declining, etc. We also know which offices need to have more time and more scheduling available.”
Efficiencies Help Streamline the Clinical Process
Clinical efficiency has been another area of emphasis for the practice, including focus on reduction of emergencies and repair visits with intensive training for the team in bonding protocols and, when possible, use of pre-coated brackets.
“A broken bracket in the first few months of treatment is our fault unless there is trauma,” says Dr. Webb. “We work very hard to reduce bond failures, poking wires, broken appliances or anything that could cause an added trip or appointment – which helps our efficiency and profitability and makes life easier for patients. We track emergencies very closely, monitoring statistics, work with staff who are having failures, etc. We rarely have bond failure after initial placement.”
In addition, Dr. Webb and all of her team wear headsets in order to communicate throughout the day, which they believe makes a difference in terms of efficiency.
“Communicating via the headsets, as soon as I finish with a patient the patient flow coordinator tells me who to go to next, and I can get immediate updates from the clinical team on that patient,” she says. “Wearing the headsets has taken a little time to get used to, and I do pull my earpiece out during exams so that the patient receives my full attention, but we feel the benefits of using the headsets far outweigh any possible negatives.
“Every effort that we have made to fine-tune our clinical treatment to reduce treatment times and appointments has increased our profit per visit,” adds Dr. Webb.
Beyond Preventing Emergency Visits: Ensure Progress at Every Appointment
“We make the most of each appointment to advance treatment, so as to ensure that the process will be finished by the estimated completion date,” says Dr. Webb. “It is easy to just ‘re-tie’ a patient when they come in because you are running behind. We don’t do that. If there is a new tooth, I am bonding it. If there is a tooth not fully engaged, I will engage it. If we can start elastics, I will start them.
“At our morning huddle, we discuss any patients who are over their estimated treatment time and try to find ways to advance their treatment,” adds Dr. Webb. “When I walk to a chair, the very first thing a clinical assistant will say to me is a code such as 12/14. This means the patient has been in braces for 12 months and the estimated treatment time is 14 months.”
Dr. Webb also emphasizes consistency in treatment plans and clinical procedures to ensure her team understands and can follow every step of the process easily.
“I look at it this way: If treatment plans, treatment philosophies and clinical techniques are all over the map, your staff and your treatment are likely to be all over the map, too,” she says. “Continually ‘trying’ new things, new brackets, new appliances leads to emergencies, staff confusion and inefficiency. Our team knows and understands the goals of treatment. They know what I would do in almost every situation and they have a game plan to follow. We use simple mechanics and easy-to-follow wire sequences. I take my time on initial bracket placement so we don’t have to reposition later, and we communicate with our patients well.”
Long-Term Focus on Profitability Leads to Continued Growth
As Dr. Webb’s practice continued to grow, in 2012 she was accepted into the Schulman Study Group. An association of nationally prominent orthodontic practices, the group’s members follow practice management principles advocated by Dr. Martin (Bud) Schulman.
In 2014 the practice opened another satellite location in Sidney, Nebraska. This location, which brings the total Nebraska offices to four, has space leased from a general dentist. The other offices are owned by Webb Orthodontics.
In 2018, Dr. Webb opened a new satellite clinic in Torrington, Wyoming to help serve the practice’s patients from that state and also purchased a practice in Cheyenne, Wyoming from a retiring doctor. Dr. Nathan Moeller, who lives in Wyoming, joined the practice as an associate in order to provide treatment at the Wyoming offices. Staff from the Nebraska locations go to Wyoming to work with Dr. Moeller in the Torrington office so as to maintain the practice systems there, and help the bring the existing Cheyenne team up-to-speed on the practice systems.
Team and Community Focus Also Add to Success
Dr. Webb believes that her emphasis on team development with the practice’s 23 orthodontic staff members, and the practice’s community marketing program have contributed greatly to success in terms of both production and profit.
“One of the really enjoyable things about practicing in a rural area is that we really get to know our patients and are involved in the community,” she says. “We actually have our own community organization ‘Webb SOCS’ (supporting our community) that we use to volunteer in our community. Everyone on our team is expected to volunteer at community events and I pay the staff for their time in doing so.”
The practice’s community activities are promoted on its social media pages and website. The grassroots approach to marketing is extended via sweatshirts with the practice logo, which are given to every patient who completes treatment.
“We see people wearing our sweatshirts all the time in each community,” says Dr. Webb. “And within the practice, each contest for our patients is tied into a community organization and helping the group in some way. We sponsor almost every group, organization, team, etc. that we can.”
To ensure that each employee is prepared to work in a way that reflects the values and goals of the practice, Dr. Webb brings the team into all decision-making, including hiring of new employees. Staff committees help manage other key functions including marketing, purchasing and facilities management.
“We do very in-depth staff reviews every year to help ensure each team member is growing in ability to contribute to the practice,” says Dr. Webb. “I feel this is important and may be overlooked in a lot of orthodontic practices.
“Apart from job functions, the most important thing is making sure that each team member reflects our practice vision and culture in terms of both work processes and how we communicate with patients,” she adds. “I love our patients; I love all kids, and my overall goal is to make each person who comes into every one of our offices feel good. Making every aspect of our culture work requires buy-in from the entire team, so it’s very important for our leadership team to pay attention to each individual’s development.”
Click here to learn how Dr. Stephen Sherman, Sr., Dr. David Balhoff, and Dr. Stephen Sherman, Jr. stayed on track with profitability.