Why do so many offices run in a mill-like fashon?

[Utdarsenal]

Serious question here. Why do so many clinics run in a mill-like fashion of non-stop bouncing from room to room?

How did dentistry turn into this? Are procedures really that unprofitable that one would have to go to these lengths just to stay afloat? Or is the reason more-so someone trying to accumulate as much wealth as possible whatever the cost may be?

I’d imagine that we studied a career that doesn’t really necessitate us to work in extreme (killing your back) fashion.. I get it to maybe cut down on student loans, but after that? Is it really that much of a catch up game or “keeping up with the jones’” situation?

As a scenario, Lets say you owned a practice and only saw 8 patients per day, each procedure being $150 (low end). That’s 1,200 bucks per day. With that amount of patients, you may only need one assistant and maybe one front desk. 2 employees x $20 x 8 hours of work =$320 on employees per day.
1,200 - 320= 880
If rent is say $3,000/mo, subtract another 100/day. So now we're at 780/day..for any other dental materials/electricity/gas etc lets add another 100, so 680 /day.

Obviously these are all ballpark numbers and I went to the extreme saying only 8 pts/day for low-paying procedures (150), and no hygienist, but worse case scenario in a low-volume clinic, you’re still walking away with approx $650+ Daily for yourself in a “very” slow paced environment. I understand people think that may be too little for their expenses.

Why exactly have we become accustomed to the 15-20+ patients/day grind?
I think this is a reason why so many dentists also hate their jobs.

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[allDAT]

It's all about $.
FQHCs are often paid per encounter, so more encounters = more revenue.

Some procedures are that unprofitable depending on reimbursement. If you're in-network with HMOs, you may not get paid anything for the exam and prophy and sometimes even fillings....Sometimes you take a PPO and it's profitable for this and that, but you lose $50 on a denture repair for example.

In your calculations, you're forgetting quite a bit. There's malpractice insurance, fees to have a license, DEA fees, business insurance, practice management software subscriptions, CC processing fees, payroll processing fees, accounting fees, mandatory training, city fees, state fees, fees for medical equipment, fees for biohazard and sharps disposal. Not to mention supply and lab costs. There are fees for this and there are fees for that. It never ends and it's not cheap to run a practice. 1k per day may be a break-even, I actually know a dentist who runs a lean shop in Southern California (3 chair office, minimal staff, and NO COMPUTERS) - high staff wages because of the area and rent of $4,100/month and it still costs about 30k/month to run the practice after you've paid for everything you need.

15 patients a day isn't bad if you're including exams. Remember - not every exam yields treatment. So you may need to do 5 exams to diagnose one crown. Since resins are reimbursed so poorly, you need crowns.

There are many reasons to hate dentistry, but there are also many reasons to love it. We have lost control of our fees and our dependence on insurance is probably permanent.

One of the biggest reasons so many of us have to practice at this pace is that we devalued the comprehensive exam. We're not paid to evaluate the patient and formulate a treatment plan and that's a huge loss to our profession and makes us more like mechanics than doctors or attorneys.

 

[allDAT]

It's all about $.
FQHCs are often paid per encounter, so more encounters = more revenue.

Some procedures are that unprofitable depending on reimbursement. If you're in-network with HMOs, you may not get paid anything for the exam and prophy and sometimes even fillings....Sometimes you take a PPO and it's profitable for this and that, but you lose $50 on a denture repair for example.

In your calculations, you're forgetting quite a bit. There's malpractice insurance, fees to have a license, DEA fees, business insurance, practice management software subscriptions, CC processing fees, payroll processing fees, accounting fees, mandatory training, city fees, state fees, fees for medical equipment, fees for biohazard and sharps disposal. Not to mention supply and lab costs. There are fees for this and there are fees for that. It never ends and it's not cheap to run a practice. 1k per day may be a break-even, I actually know a dentist who runs a lean shop in Southern California (3 chair office, minimal staff, and NO COMPUTERS) - high staff wages because of the area and rent of $4,100/month and it still costs about 30k/month to run the practice after you've paid for everything you need.

15 patients a day isn't bad if you're including exams. Remember - not every exam yields treatment. So you may need to do 5 exams to diagnose one crown. Since resins are reimbursed so poorly, you need crowns.

There are many reasons to hate dentistry, but there are also many reasons to love it. We have lost control of our fees and our dependence on insurance is probably permanent.

One of the biggest reasons so many of us have to practice at this pace is that we devalued the comprehensive exam. We're not paid to evaluate the patient and formulate a treatment plan and that's a huge loss to our profession and makes us more like mechanics than doctors or attorneys.

I should clarify. I said the dentist I know spending 30k/month has high staff wages - they're actually not outrageous. $18/hr for an assistant and $48/hr for a hygienist, and $22/hour for his receptionist. Hygienist practices 4 days a week. Office is open 7 hours/day 4 days a week.

 

[Molar Whisperer]

Serious question here. Why do so many clinics run in a mill-like fashion of non-stop bouncing from room to room?

How did dentistry turn into this? Are procedures really that unprofitable that one would have to go to these lengths just to stay afloat? Or is the reason more-so someone trying to accumulate as much wealth as possible whatever the cost may be?

I’d imagine that we studied a career that doesn’t really necessitate us to work in extreme (killing your back) fashion.. I get it to maybe cut down on student loans, but after that? Is it really that much of a catch up game or “keeping up with the jones’” situation?

As a scenario, Lets say you owned a practice and only saw 8 patients per day, each procedure being $150 (low end). That’s 1,200. With that amount of patients, you may only need one assistant and maybe one front desk. 2 employees x $20 x 8 hours of work =$320 on employees per day.
1,200 - 320= 880
If rent is say $3,000/mo, add another 100. So 780 minus.. for any other dental materials/elecricitt/gas etc lets add another 100, so 680 /day.

Obviously these are all ballpark numbers and I went to the extreme saying only 8 pts/day for low-paying procedures (200), and no hygienist, but worse case scenario in a low-volume clinic, you’re still walking away with approx $650+ Daily for yourself in a “very” slow paced environment. I understand people think that may be too little for their expenses.

Why exactly have we become accustomed to the 15-20+ patients/day grind?
I think this is a reason why so many dentists also hate their jobs.

Since I am not a practice owner, I may get shot down by many. I think there are a lot of holes in your scenario. My sister (practice owner) mentioned she needed to have about a dozen insurances. If your clinic is all paid for, you might see ~50% overhead. If not, you need to pay the equipment, maybe finance the purchase of the practice or startup costs. You need to factor in taxes and many offices outsource their HR. Do you clean your own toilets? Usually rent in a high traffic area depending on the size will be higher than $3000 unless you are in the middle of a ghost town (a kiosk at my local mall is $5000/month). You don't plan on opening 30 days a month so the rent calculations per day is inaccurate. One location I worked about 10 yrs ago was $15,000/month.

You can try to accept only good paying insurance or cash. My 3 months at a small private practice chain was that way and we had no foot traffic. They promptly closed that location when I left. I don't believe in "mill-like" flow. Some procedures require more time than others and regardless of how many patients you see, you cannot rush through them. It's very important to focus on efficiency and lowering overhead. From many stories, the first few years may not realize any profit.

 

[Molar Whisperer]

My USAF buddy had just started his practice in 2002 and called me shortly after to complain how much they were charging to dispose sharps...I forgot like $50? There are a lot of unforeseen expenses we may not realize until we have to pay for them. It's good to have multiple incomes when you start a practice such as spouse's income, etc. When you get established, hopefully you will reap the rewards.

 

[charlestweed]

Because not every patient pays $150. Medicaid pays around $50 per filling. Many HMO plans pay $0 for a filling. Many of these busy clinics hire associate dentists.....so in order for them to pay associate dentists $600/day, the associate dentists have to produce for them at least $2k day.

You are right. You don't need to work nonstop and jump from chair to chair, if you are an owner of a low overhead office. My sister doesn't have a lot of patients because she is practicing in a very saturated market in SoCal. Her office accepts everything including medicaid....but no HMO. Currently, she works 5-6 hours a day 4-5 days/wk. She only sees 5-6 patients/day on the weekdays and 8-10 patients on Saturdays. She only uses 2 chairs. Every time I walk into her office, I usually see an empty waiting room. With low overhead and passive income from in-house perio and ortho, my sister is doing way better than a lot of the associate dentists, who work like dogs at the corp offices.

IMO, making $650 a day is only enough for yourself. If you have kids to support and want to retire comfortably in an expensive state like CA, you need to make a lot more than that. You need to make more money so you can invest for your future retirement.

 

[Utdarsenal]

Ok wow, thanks everyone for putting things into perspective. So, there are a s#it ton of things that have to be paid "behind the scenes"..

 

[TanMan]

Serious question here. Why do so many clinics run in a mill-like fashion of non-stop bouncing from room to room?

How did dentistry turn into this? Are procedures really that unprofitable that one would have to go to these lengths just to stay afloat? Or is the reason more-so someone trying to accumulate as much wealth as possible whatever the cost may be?

I’d imagine that we studied a career that doesn’t really necessitate us to work in extreme (killing your back) fashion.. I get it to maybe cut down on student loans, but after that? Is it really that much of a catch up game or “keeping up with the jones’” situation?

As a scenario, Lets say you owned a practice and only saw 8 patients per day, each procedure being $150 (low end). That’s 1,200 bucks per day. With that amount of patients, you may only need one assistant and maybe one front desk. 2 employees x $20 x 8 hours of work =$320 on employees per day.
1,200 - 320= 880
If rent is say $3,000/mo, subtract another 100/day. So now we're at 780/day..for any other dental materials/electricity/gas etc lets add another 100, so 680 /day.

Obviously these are all ballpark numbers and I went to the extreme saying only 8 pts/day for low-paying procedures (150), and no hygienist, but worse case scenario in a low-volume clinic, you’re still walking away with approx $650+ Daily for yourself in a “very” slow paced environment. I understand people think that may be too little for their expenses.

Why exactly have we become accustomed to the 15-20+ patients/day grind?
I think this is a reason why so many dentists also hate their jobs.

You want to bounce from room to room, otherwise, you have idle, unbillable hours. We don't get paid hourly, nor do we get paid to talk. I don't think you can generalize all of dentistry as turning into a mill. Everyone has different practice styles and incentives. Procedure profitability is based on doctor speed and expenses. Taking longer doesn't always make sense clinically nor financially. If I'm idle, I'm bored AF. Your equation for the rent should be rent / # of days worked, not # of days in the month. That increases your rent/day. Staff costs tend to be higher, many dentists have notes to payoff, lifestyles/retirement to fund. Insurances reimbursements are lower, insurance patients subsidize themselves by sharing alloted times with fellow insurance patients.

Better question is why you would consider 15-20+ patients/day a grind. I don't think it's a grind at all. That can be knocked out within 2-3 hours, depending on procedure mix. They key is efficient systems and efficient assistants.

 

[AONLINE]

A genuine question for practicing dentists in this thread: with this whole pandemic/PPE shortage going on, do you think that dentists can still bounce between patients when they open again?

 

[Molar Whisperer]

A genuine question for practicing dentists in this thread: with this whole pandemic/PPE shortage going on, do you think that dentists can still bounce between patients when they open again?

Too many patients will need to come in, but will their insurance still be available after missing work?

 

[Molar Whisperer]

Having your own practice is still very desirable. It can be the most tax friendly entity. W-2 associateship provides no means to deduct your out of pocket expenses such as CE, licensing, dental assoc & DEA fees, etc. You can be an independent contractor but it is like going to the Casino. The owner (House) always wins. Private Practice has the most potential to earn and accumulate wealth. You can hire a rock star Office Mgr (discussion from a poster) and staff and make your day go smooth with minimal stress. After you retire, you can sell your practice and recoup your equity.

If all the unknowns and BS assoc with private practice are not your cup of tea, consider buying commercial property. You get the same tax advantages. After the Covid crisis, there may be good inventory of available spaces at rock bottom prices. You can rent it to dentists or better yet, rent it to OMFS and price it to match their egos...LOL.

 

[P7898]

To OP, not everyone pays ini front and on time and what your fees are. But in FFS practice, payment up front, this works.

 

[TanMan]

A genuine question for practicing dentists in this thread: with this whole pandemic/PPE shortage going on, do you think that dentists can still bounce between patients when they open again?

I think the whole PPE crisis is overblown (for dentists). Registration will eventually lead to confiscation. Probably shouldn't say this, but I got enough PPE (legit, not fake n95) to last me and my local colleagues for at least November. Been giving some out to nurse/doc patients and also specialists who refer to me . Patients are willing to pay for it. The day that a patient refuses to pay, they can always go to a less safe office.

Many of my colleagues have been afraid of registration/confiscation of PPE. It is sad that we are giving up our constitutional freedoms so easily. Don't forget the 4th amendment.

 

[P7898]

I think the whole PPE crisis is overblown (for dentists). Registration will eventually lead to confiscation. Probably shouldn't say this, but I got enough PPE (legit, not fake n95) to last me and my local colleagues for at least November. Been giving some out to nurse/doc patients and also specialists who refer to me . Patients are willing to pay for it. The day that a patient refuses to pay, they can always go to a less safe office.

Many of my colleagues have been afraid of registration/confiscation of PPE. It is sad that we are giving up our constitutional freedoms so easily. Don't forget the 4th amendment.

This will only bump up the price of dentistry. People already complain about it but the fact that now they know why we are increasing the prices, they will actually understand and appreciate it. I agree.

 

[TanMan]

This will only bump up the price of dentistry. People already complain about it but the fact that now they know why we are increasing the prices, they will actually understand and appreciate it. I agree.

The cost of doing business just went up. However, with ppe fees, we can recoup the costs back. 50 * 60 patients/day = 3k/day. A mill is still viable with those numbers.

 

[P7898]

The cost of doing business just went up. However, with ppe fees, we can recoup the costs back. 50 * 60 patients/day = 3k/day. A mill is still viable with those numbers.

People will pay for PPE fees. A whole bunch of dentists are going to charge them. If you don't charge PPE fee people might go to another dentist not even kidding haha

 

[TanMan]

People will pay for PPE fees. A whole bunch of dentists are going to charge them. If you don't charge PPE fee people might go to another dentist not even kidding haha

Not just that, but do you really want someone who's going to fight you over 50 bucks?

 

[P7898]

Not just that, but do you really want someone who's going to fight you over 50 bucks?

Hell no. Especially if it protects themselves, the staff, the dentist, and everyone in the practice.

 

[allDAT]

Not just that, but do you really want someone who's going to fight you over 50 bucks?

Are you really charge a $50 PPE fee? That would be fine with me. I'm sure insurance is going to push back and say that's part of the procedure and is unbundling.

 

[OMSDoc]

People will pay for PPE fees. A whole bunch of dentists are going to charge them. If you don't charge PPE fee people might go to another dentist not even kidding haha

I tried to do this for years, and I am very rigorous about PPE and sterility. Managed care companies (and Medicare and Medicaid) make you write this off, which means only the cash-paying patients pay it.

Any ideas?

 

[TanMan]

Are you really charge a $50 PPE fee? That would be fine with me. I'm sure insurance is going to push back and say that's part of the procedure and is unbundling.

Yes (I'm charging now, and people aren't complaining). I don't bill the insurance and my state allows me to charge what I want for a non-covered service. Insurances (except Medicaid/Medicare) can't force you to not charge for a non-covered service. Insurances only care when it's money out of their pocket. If hospitals can charge you 20 dollars for gauze or a vet can charge you 5 dollars for infection control fee, this is a totally legitimate charge, just something that wasn't customarily charged until the standards changed. Now, let's say that you're in a state that doesn't have the luxury. I'd create a new LLC that bills the patient directly for facility use.

 

[allDAT]

Yes (I'm charging now, and people aren't complaining). I don't bill the insurance and my state allows me to charge what I want for a non-covered service. Insurances (except Medicaid/Medicare) can't force you to not charge for a non-covered service. Insurances only care when it's money out of their pocket. If hospitals can charge you 20 dollars for gauze or a vet can charge you 5 dollars for infection control fee, this is a totally legitimate charge, just something that wasn't customarily charged until the standards changed. Now, let's say that you're in a state that doesn't have the luxury. I'd create a new LLC that bills the patient directly for facility use.

This might be a reasonable idea. Thanks for sharing it.

 

[TanMan]

This might be a reasonable idea. Thanks for sharing it.

You make it seem like I don't have reasonable ideas

 

[2TH MVR]

Serious question here. Why do so many clinics run in a mill-like fashion of non-stop bouncing from room to room?

Look. When you have your own practice ..... the desire to produce more comes with the territory. You're running a small business. You're working for you and your family. I look at every NP as a challenge to start. Each NP is like a potential gold mine. A healthy business is growing .... not just making enough to pay the bills. During my heyday .... I met with my acct every quarter to discuss the practice financials. I was disappointed if my production and collection numbers weren't increasing. This led to building additional practices. I enjoyed this level of work and the excitement of seeing higher and higher levels of production. You work harder because it's more exciting. Just ask @TanMan . @charlestweed . @Cold Front et el.
Of course .... at some point ..... your practice will plateau. <heavy sigh>. It happens due to age, non-interest, etc. etc. When it does .... it's just not as exciting.

You call it a mill. With the right staff ..... I call it a finely tuned dental practice.

A Corp mill. Well .... that's a whole different scenario. I'm in Corp now. I like to produce, but what is seriously holding me back is the lousy staff.

 

[yappy]

Look. When you have your own practice ..... the desire to produce more comes with the territory. You're running a small business. You're working for you and your family. I look at every NP as a challenge to start. Each NP is like a potential gold mine. A healthy business is growing .... not just making enough to pay the bills. During my heyday .... I met with my acct every quarter to discuss the practice financials. I was disappointed if my production and collection numbers weren't increasing. This led to building additional practices. I enjoyed this level of work and the excitement of seeing higher and higher levels of production. You work harder because it's more exciting. Just ask @TanMan . @charlestweed . @Cold Front et el.
Of course .... at some point ..... your practice will plateau. <heavy sigh>. It happens due to age, non-interest, etc. etc. When it does .... it's just not as exciting.

You call it a mill. With the right staff ..... I call it a finely tuned dental practice.

A Corp mill. Well .... that's a whole different scenario. I'm in Corp now. I like to produce, but what is seriously holding me back is the lousy staff.

It sounds like you have had a lot of experience and I really appreciate your perspective. Did you ever struggle with focusing on new sales/growth VS being an advocate for your patients? How does one ethically balance the need or desire for new growth for their business, or someone else's business, while also treating a patient ethically.

 

[charlestweed]

It sounds like you have had a lot of experience and I really appreciate your perspective. Did you ever struggle with focusing on new sales/growth VS being an advocate for your patients? How does one ethically balance the need or desire for new growth for their business, or someone else's business, while also treating a patient ethically.

Work hard: Spend time to take good care of your patients. Don't try to cut corners. Make yourself available to treat emergency patients on the weekends and late hours. Always assume that each patient may come back to sue you....so to avoid this, do good work. For the specialists to continue to get referrals from GPs, they have to do good work....GPs constantly evaluate their works. For general dentists, a lot of happy patients = more word of mouth referrals = practice growth. Unhappy patients, lots of redos, lots of complaints, unethical dentist = failure of a practice.

Keep the overhead low: When you have low monthly fixed expenses and zero business loan debt to repay, you don't need to produce a lot in order to be profitable. With less pressure to produce, you tend to do more right things for your patients.....no sale, no advertisement. Patients trust you when you are honest to them.

Being a competent dentist. Take CE classes to improve your clinical knowledge. Lack of clinical experience will hurt your patients. Don't be afraid to treat challenge cases. If you hate doing endos because you don't think you are good at doing them, you need to do more endos, instead of asking the senior owner doctor to do them for you. Being in good and fast will help you see more patients in a day.

 

[Cold Front]

Yes (I'm charging now, and people aren't complaining). I don't bill the insurance and my state allows me to charge what I want for a non-covered service. Insurances (except Medicaid/Medicare) can't force you to not charge for a non-covered service. Insurances only care when it's money out of their pocket. If hospitals can charge you 20 dollars for gauze or a vet can charge you 5 dollars for infection control fee, this is a totally legitimate charge, just something that wasn't customarily charged until the standards changed. Now, let's say that you're in a state that doesn't have the luxury. I'd create a new LLC that bills the patient directly for facility use.

ADA released a guidance on billing insurances for PPE cost per patient earlier this week. You can bill insurances under D1999 now, even some state medicaid insurances covers it. This will be the new norm in the short term.

https://success.ada.org/~/media/CPS/Files/COVID/ADA_Third_Party_Payer_Reimbursement_for_PPE.pdf

Sent from my iPhone using Tapatalk

 

[P7898]

ADA released a guidance on billing insurances for PPE cost per patient earlier this week. You can bill insurances under D1999 now, even some state medicaid insurances covers it. This will be the new norm in the short term.

https://success.ada.org/~/media/CPS/Files/COVID/ADA_Third_Party_Payer_Reimbursement_for_PPE.pdf

Sent from my iPhone using Tapatalk

What is the amount given? Anyone know?

 

[OSOSOS]

I think it’s super important that you noticed this. If it does concern you, realize you MUST go a certain direction with your practice if you want to avoid this. If you are heavy PPO, most offices must see a volume of patients just to make the math work out. Even if you don’t want to make a good income as a dentist, the business should still be profitable and the numbers need to work with overhead.

“mill” or “Rollwr skates” etc doesn’t always mean dentistjust wants a boat. The dental office machine is big and hungry and needs to be fed.