Off Script

Underwater

I’ve been underwater before. Teaching myself to swim in preschool didn’t go well. Neither did that homemade rope-swing over the Russian River five years later. I was exactly 60 feet underwater when I got stuck SCUBA spelunking. That was an unpleasant half hour of very slow breathing. I’m still underwater with that can’t lose property I bought in Arizona… my wife won’t let me forget that one.

   

Two weeks ago I found myself underwater again. Aimee and I had just purchased two new cone beam CTs, namely ridiculously accurate and powerful Planmeca Promax 3D Max’s. Only five 3D Max’s are currently in California: a plastic surgeon, an oral-facial surgeon, a surgical teaching facility… and Reveal Diagnostics in San Francisco and Mountain View. But the new technology didn’t put us underwater.

 

Two weeks ago, we also opened two new 3D dental imaging centers. We’re now scanning in Mountain View and Marin, as well as our flagship office in San Francisco. But it wasn’t tripling in size that put us underwater.

   

It was the water. Literally. Two weeks ago we walked into our San Francisco office and found a flood. The dental office above ours flooded. Actually it started flooding when the doctor left his water running Thursday afternoon; by Monday morning it was more of a monsoon. That monsoon soaked our carpet, warped the baseboards, infiltrated the drywall, and even seeped into the conference room table so thoroughly the legs split. It hit everything but our new cone beam and the office computers. We were seriously, literally, wetly underwater.

Luckily I had an ark! Her name is Aimee. In two weeks Aimee had the insurance wrangled, the water extraction team organized, the carpet replaced, and a few thousand other things taken care of… She was like a giant blow dryer for water and the problems it caused. I may mock or terrorize her most every business and weekend day, but at catastrophic moments like this (and on most other business and weekend days) my business partner is pretty amazing. My soaked point is sometimes you know you could end up underwater; I just co-signed a loan for my niece… Sometimes you don’t, and you walk into an office swamp. For those surprise underwater moments, get yourself a lifeboat or an Aimee. But you can’t have mine!

  

 

 

 

The delta between Delta and doctors

Most dentists view insurance as a necessary evil. For those eight who don’t, Delta is making it that much easier. Delta has quietly been changing its evil ways… and not at all for the better for doctors or patients.

 

A quick review: Delta Premier is/was/should be the best insurance for everybody. Dentists get reimbursed at or near their standard fees, meaning dentists can afford to take adequate time, hire well-trained staff, invest in technology, use premium materials, and send work to high quality labs. Employers get the widest network of dentists. Patients get the best possible care, through a wide selection of dentists who are compensated enough to provide high quality service.

 

By contrast, Delta PPO sucks. Dentists are typically reimbursed at 40 to 70% of their regular fees. Remember dental offices typically operate on average at 65-70% overhead. PPOs reimburse at less than the cost of running a business, or at best about break-even. This raises the prickly question of how a dentist can stay in business when each PPO patient actually costs the doctor money to treat. Wouldn’t it be cheaper to not see PPO patients and keep the office closed? There are a few things PPO doctors can do to keep their doors open, and a few things you may tell yourself so you can sleep at night:

  • Lower expenses by hiring less experienced staff, using cheaper materials, and not upgrading equipment or technology

You tell your patients “you get what you pay for,” but that doesn’t necessarily apply to a $10.25/hour assistant or discount composite with foreign-language instructions

  • See more patients per hour by working faster

Rushing through procedures; what could possibly go wrong?

  • Use cheaper labs and cheaper restorations

There’s no certainty that the patient will experience an adverse reaction to a $19 PFMM (porcelain fused to mystery metal) that was made in an overseas sweatshop suspiciously located next to an auto scrap yard

  • Up-sell elective procedures that aren’t covered/limited by the PPO

This creates an uncomfortable sell-or-starve atmosphere that is better suited to Time Share sales or an episode of The Dental Apprentice than to dental offices

  • Increase the fees for your nice non-PPO cash-paying patients

Which penalizes non-PPO patients and is just plain unethical in some US states and Puerto Rico

 

I don’t mean to single out Delta’s PPO. Almost all dental PPOs rate sub-sewage, so I don’t mean to imply that Delta’s PPO is uniquely bad. I mean to single out Delta Dental as a company, because Delta happens to be uniquely bad in other ways… which I’ll explain now.

 

First understand that Delta Dental is a business, and good businesses make money, and Delta is a very, very good business. Several years ago, to increase profits, counter emerging Metlife and Aetna, and remain the Walmart of dental insurance, Delta began promoting its PPO over its Premier plan. This was originally done by switching Premier patients/employers over to PPO. That’s bad for dentists but not necessarily shady business. Non-PPO dentists who were in the Premier program were still getting reimbursed at their contracted Premier rates.

 

Until now…

  • Delta wants to claim the highest number of in-network PPO dentists
  • Any dentist who wants to apply for Premier must also accept PPO
  • When an associate joins a Premier practice, the practice must accept PPO or lose its Premier status
  • Ditto for practices being sold to associates

 

Okay, you may shrug. So I have to accept PPOs as well as Premier. My Delta patients are all Premier so it won’t affect me… will it? The answer is a crushing YES.

 

Even IF the patient is a Premier partner, if the doctor accepts PPO as well as Premier (which doctors are being coerced to do), Delta will reimburse the doctor at the lower PPO rate.

 

Re-read that above statement 3 more times… Stings, doesn’t it? Even worse, Delta never announced this policy change. My dental friends suddenly and surprisingly found out, kind of like the Titanic captain found out there was an iceberg around. Some dentists are still blissfully cruising full speed ahead through treacherous waters.

 

How bad is the situation? Look at the ramifications.

  • If you’re accustomed to your Premier income, you’re heavily disincented to take on an associate and slash those reimbursements in half
  • If you’re buying a practice, the income and profitability projections under a Premier-only dentist will be much higher than you (as a new PPO dentist) can expect
  • Banks know the above point, so getting a loan for a highly profitable Premier practice will be more difficult and expensive
  • If you’re selling a Premier practice, it’s worth a lot less to a new dentist who can only collect PPO fees… which cuts the value of that heavy Delta Premier practice you were counting on for retirement

 

You can avoid this by dropping Delta, maybe, but Delta won’t go without a fight.

  • Delta typically refuses to tell out-of-network dentists how much they can expect for reimbursement of most procedures
  • Delta now refuses to pay out-of-network dentists directly, even if the patient signs the standard request that the money go to the dental office
  • This forces out-of-network dentists to bill patients up front, with no clear idea of reimbursement expectations

 

So you might have to stick it out with Delta after all, which is a lot worse than expected but not catastrophic. Or so you tell yourself. Actually, the catastrophe is on its way to a state near you. In addition to the above maneuvers, Delta has also been cutting reimbursements systematically (state-by-state) to reduce everybody to PPO levels. There’s less outrage if one state gets nailed. After a majority of states have converted, it’s easier to tell the big ones like California and New York they just have to follow the trend.

  • Delta reports they set the reimbursement fee at the 80th percentile of dentists “in the area,” which oddly seems to include rural Alaskan dentists-veterinarians-fishing guides, regardless of where you live
  • In June 2011 Delta cut back those reimbursements in Washington state by 15% (meaning Delta is now reimbursing at the 68th percentile, assuming they actually started at the 80th)
  • In November 2011 Delta cut the Idaho state reimbursements by 8%
  • Delta seems to be converging its Premier and PPO fees, so even if you’re Premier and haven’t succumbed to accepting PPO fees, soon there won’t be much of a difference

 

As I said earlier, these are pretty evil developments for doctors and patients alike. Before you take out your Delta Voodoo Dolls or organize Occupy Delta rallies, this could be indicative of all insurance to come (meaning you’ll at least need more voodoo dolls). Insurance companies are exempt from Federal Trade Commission anti-trust laws and are therefore allowed to collude and prices and services, even though they are competitors. This looks like the beginning of a large-scale squeeze on doctors and their patients. On the other hand, if you’re an executive or shareholder of Delta Dental, evil can be quite profitable.

 

What do these three have in common?

Coming soon: what you can do to fight the future, besides unleash the Occupy My Street protestors on them…

New Year, New Plan, Same Guy

I gathered our office together this week for a “New Plan for the New Year” brainstorming session. Lindsay, my way-too-comfortable office manager, started the discussion with: “let’s use the old plan, but this time actually stick to it.”

 

It was a really short meeting.

 

Lindsay was completely right (as well as completely annoying). I’d spent a lot of time putting together 3D imaging systems and plans… and not a lot of time implementing them and keeping them in place. Ditto for my plans on exercise, dieting, and helping with laundry. My only resolution for 2012 is to post and re-read and re-re-commit to my resolutions of 2011 (and 2006-2010, minus that resolution to become a competitive hotdog eater).

 

After some thought and less than a week of reading the 2012 news, I did add a few more do’s and dont’s to my resolution list:

  • Do Occupy something before the movement has moved on (I missed the 60′s)
  • Don’t shank an easy Bowl game-winning field goal (or two in Stanford’s case)
  • Do work hard for every vote (they count in Iowa, not so much in Russia)
  • Don’t carry a loaded gun through airport security
  • Do expand Reveal to three or four locations (had to slip some work CBCT in here)
  • Don’t marry a Kardashian (especially the skinny one)
  • Do treat 2012 like it’ll be the best year in your life (just in case the Mayans were right)

 

Happy 2012! I hope your resolutions get more attention than dust!

 

Marshall & The Reveal Diagnostics Team

 

 

 

2011 Year in Verbatim

As we’re wrapping up 2011 and our first calendar year in the 3D dental imaging business, Aimee and I began collecting our favorite quotes of the year. None of the embarrassing ones were uttered by you, I promise.

 

“Seriously, you two are doing what?” – almost everybody at Patterson

 

“When you’ve gotten that out of your system, give us a call.” – everybody at Schein

 

“I’ll ask you for decorating advice when I want that men’s locker room feel.” – Aimee to Marshall

 

“I don’t usually take on fashion projects, but for you I’ll make a huge exception.” – Aimee to Marshall

 

“If I wanted this much abuse I’d stay home with my wife and kids.” – Marshall to Aimee

 

“You two ever consider couples counseling?” – Our CRT Darin to Marshall and Aimee

 

“I use my cone beam only after placing implants, mainly to see how well I did.” – Doctor who uses his cone beam only after placing implants

 

“Can you tell me how bad it is before you show me the picture?” – Doctor who had bad news coming

 

“What can I say about this case that hasn’t already been said about Somalia?” – Marshall delivering bad news

 

“Wow, 3rd world dentistry looks a lot worse in 3D.” – Doctor fixing work done overseas

 

“I’m putting an end to country music in the office. I think I’ve grown dumber for having listened to it.” – Marshall to our office manager Lindsay

 

“You’re right on the dumber part, wrong on the cause.” – Lindsay’s reply

 

“Our software is so much better… because… well, everybody just says it is.” – Sales person for software we didn’t buy

 

“The power’s out in the office. I plugged in both space heaters and was using the microwave. You know, this also happened the last time I plugged in both space heaters and used the microwave.” – Aimee

 

“And you thought this time would be different because…” – Marshall’s reply

 

“I got divorced for a reason.” – Aimee’s reply to Marshall’s reply

 

“You guys can say on your blog what doctors can’t for fear offending of the insurance mafia and the stingy patient!” – the one doctor who reads our blog

 

“I’m so glad I can stop by here and tell jokes that would get me sued in my own office.” – Doctor with great jokes

 

“Your face is beautiful… with all the flesh gone and just the bones left.” – Marshall trying to compliment patient

 

“Every dentist I’ve every worked with graduated in the top 1% of their class and truly the best in the city. It’s statistically amazing.” – Oral surgeon, who also graduated in top 1% of the class

 

“The closest I’ve gotten to dental school is the mandatory biology class in high school, but I did get an A.” – Marshall’s disclaimer when offering an opinion

 

“There’s almost no difference between screwing and implant into bone and a wood screw into wood.” – Doctor/carpenter on screwing

 

“I swear I’ll delete your calendar so you’ll have time to get that done!” – our office manager Lindsay to Marshall

 

“Actually I’ve had plenty of opportunities to get that done. I just chose to ignore them all, like ghosts or drunken relatives.” – Marshall on prioritization

 

“Would you mind stopping by for a quick CEREC question? The patient’s in the chair right now.” – Doctor in my building with a not-so-quick CEREC question

 

Patients’ comments when viewing their 3D skull and images:

  • “Why can’t I see my brain?”
  • “So that’s what I’ll look like when I’m dead!”
  • “Is that really me?”
  • “Yuck! Can you photoshop that?”
  • “Can I have this for my Facebook profile?”
  • “If insurance doesn’t cover this it must be good for me.”
  • “Can somebody buy a cone beam for personal use?”
  • “Can I have that for my fourth grade science project?”
  • “I felt my pineal gland move during the scan!”
  • “This office has really great psychic vibes.”
  • “You guys do CBT? No way!” (google CBT; it’s not Cogitative Behavioral Therapy)
  • “Am I in the right place? You guys seem way too happy to be in dental.”
  • “You four could be your own sit-com.”

 

We hope you make the most out of the last few days of 2011, and we look forward to seeing and helping you in 2012.

 

Sincerely,

The Reveal Team

Top Ten Reasons Your Dentist Hates You Back

A friend sent me a semi-hilarious list entitled Top Ten Reasons You Hate Your Dentist. I’m no dentist; I own a San Francisco 3D dental imaging center. However, I spend enough time with dentists (huddled around cone beam x-ray images or around bottles of wine) to empathize with their plight. So I wrote a response for that small 90% of patients who might not get it…

Top 10 Reasons Your Dentist Hates You Too

10. I’m a lot sorrier than you that you’re late. You’re upset there was a red light, dirty diaper, chatty boss, or trivial errand that prevented you from showing up on time. I’m upset I have an expensive staff and half million dollar office and equipment loan that I need to pay for, and we’re looking at an empty chair while you check Facebook one last time before leaving home. Now I have the ethical choice of treating you in half the time (with twice the chance of sacrificing quality) or giving you the full treatment and inconveniencing all of my patients and staff for the rest of the day. It’s a tough choice.

9. I am sincerely sorry you’ve been sitting in the waiting room for 30 minutes. You have a right to be upset. Direct that anger at the patient who showed up late (see above Reason 10) and take it out on him in the parking lot. Next time if you’re late and a patient punches you in the parking lot, you’ll know why. If you miss an appointment I may punch you myself.

8. No, you can’t pay me later when you have the money. You can’t buy a venti carmel frappachino without first surrendering $4.65 plus tax. I know you know this; I just scraped six months of Starbucks film off your teeth. By the way, a daily Starbucks adds up to $1,300 per year and causes tooth decay. You somehow found the money to cause the double-shot non-fat extra-whip problem; you can find the money to fix it.

7. I know you’re in extreme pain and you feel it’s a do-it-right-now emergency. In your mind this probably has nothing to do with my recommendation last month of “do it right now or you’ll be in extreme pain.” In my mind it’s a lesson, and at 10pm on a Friday it’s also annoying. Did you think I was joking when I showed you the ginormous cavity on the x-ray, or did you think I’d rather miss my kid’s ballgame and see you on a Saturday? Go medicate yourself and pray my kid wins the game so I’ll be in a good enough mood to come in early Monday morning.

6. I didn’t break it, and I don’t really care who did. If your tooth is broken it’s hard to claim it’s not your fault with a straight face. If you try I may leave your face crooked. More to the point, I don’t care unless I ask (and I won’t). If it’s your tooth in your head then it’s your responsibility and you’re paying to get it fixed. Don’t think that because I placed the crown twelve years ago or put in a filling two teeth over that suddenly I’ve insured your whole mouth for life. Or if you think it, don’t every say it. I’m the guy holding very sharp things near very sensitive places.

5. Yes I know you can get this service cheaper somewhere else. You didn’t think I knew about the 19-year-old down the street with the semi-legal dental license who offers $195 crowns? I pay my lab more than that for the crown. The cheaper guy pays $19 for crowns that were used car parts in a Chinese junk yard last week. He also spends 12 minutes on the total procedure; I spend an hour and a half. I’m sure my quality and his are comparable to apples and asphalt, but since that doesn’t matter I suggest you call him on your iPhone 4Gs then hop in your Mercedes SL and go see him to save a buck. In addition to tattoos, car seats, and airport security, your health is a fine thing to bid out to the lowest bidder.

4. Of course there’s another, better treatment to what I suggested. I based my opinion solely on a long and ongoing education and lifetime of experience, but I understand you’re looking for something faster or cheaper or less detailed. Let’s extract the tooth. Yes, Plan B is to yank the whole tooth out of your mouth and it will never bother you again. That’s dentistry in most of the world and you seem like a worldly person. Would you like me to do it, or do you have pliers at home?

3. You treat my bill like it’s the decaying filth I just spent an hour scraping out of your mouth.  Do you really think I’m stealing your retirement savings so I can buy a third vacation home on the French Riviera. I’m lucky I can afford a croissant. I came out of dental school with $300,000 in debt and then paid another $500,000 to buy and modernize my practice. My staff refuses to work for free, the landlord demands rent, and I have foolishly decided to buy thousands of dollars in brand new disposable items for each operation–when recycling cotton rolls and gloves and needles would lower the cost for everybody. You’re paying a very fair price so smile with those teeth I just fixed.

2. You’re really upset insurance isn’t paying for all of it? What about my feelings? I’m King-Kong-with-dandruff furious that insurance is forcing my fees down to those of a semi-retired dentist/goat herder in North Dakota, while forcing me to hire an employee just to decrypt the codes for submitting eighty-one forms to get my meager insurance reimbursement four months from now. You suspect insurance is short-changing you, but I know it’s fleecing me. Yet somehow you believe the shoddy contract between your employer and a multi-billion insurance company is my fault.

1. Wow, I hurt you. I did it intentionally because I became a doctor to hurt patients rather than help them. I only blew a puff of air on your diseased gums and  exposed tooth roots… and I’m the one causing the pain? That’s like blaming the nasty hard telephone pole for ruining your car, as you were driving 20 mph and 1.2 blood-alcohol over the limit. Introduce your mouth to 1870s technology: brush and floss. Then I won’t hurt you as I try to repair years of oral neglect.

I know you hate your dentist. It’s mutual. I’ll see you next week for your appointment. And thanks again for your referrals.

 

 

Occupy My Street

We’re now two months into the nationwide Occupy Wall Street-palooza! Although there’s only the Wall Street in New York, and most of the greedy million-dollar-bonus firms have long since moved away, people from Santa Rosa to Salt Lake want a piece of the action. That includes me. I wasn’t alive during Woodstock and Burning Man is too far of a drive. Plus I love s’mores. So Saturday afternoon I packed my Eddie Bauer and North Face camping gear, grabbed plenty of Evian (at $6.90 a gallon), and hopped in the Prius to drive 1.2 miles to Occupy Palo Alto. I was most concerned about parking, as the campout probably coincided with another art and wine festival. Hopefully there would be valet nearby…

Then my wife caught me. Ashley knows I only clean the garage when looking for Christmas presents, so any pre-December rummaging signaled something bad. She stopped me in the driveway and verbally thrashed me.

Ashley: Hey, sweetie. Where are you going?

Me: To Occupy Palo Alto!

Why?

Because… it’s time to occupy!

Storm the castle, that sort of thing?

Exactly!

And what do you hope to accomplish after you take the castle?

I tried to envision a castle on University Avenue; I suspected she was being allegorical… or just female. Few women I know appreciate a good castle storming (or movies about it), and my wife obviously enjoyed mucking it up with questions about motive and purpose.

Ashley (laughing): You know this movement is about economic inequity.

Me: Exactly! And thanks for the prompt.

And about lack of a political voice.

Exactly again! You’re good at this.

So why don’t you work harder on your 3D x-ray business to earn more money, and vote to change the politics you don’t like?

I waited for a moment, hoping this was a rhetorical question and wouldn’t require much thought or response. It was a long wait. I finally answered in a very un-castle-storming voice.

But I like camping and s’mores and protesting…

Then invite your fraternity friends over and pitch tents in the back yard. That will be easier on everybody.

So I did. And it was much easier! At s’mores time my daughters even joined the protest, which devolved into a protest over limiting their chocolate intake. At the end I appreciated Ashley’s helpful protesting suggestions. We didn’t actually storm a physical castle, but I also didn’t have to worry about parking.

Goblins, Ghosts, Ghouls, and Dentists

Tonight my four-year-old Riley will dress up as Little Bo Peep and my two-year-old Jordan will be a sheep. Riley has been practicing with her hooked staff for weeks. I expect Riley-Peep to professionally herd Jordan away from all dangers seen and imagined. Yet the biggest dangers will remain unseen and both girls–along with all kids nationwide–will fall victim to their twisted group scheme.

 

These sinister Halloween horrors are dentists. The diabolic scheme is Halloween itself.

 

Years ago I was exploring a secret underground passage that connects UOP and UCSF; I was looking for a lost treasure of CEREC blocks, hidden by the Templar dentists. I discovered a crumbling parchment written in Aramaic. (UOP’s restorative department still uses Aramaic in its treatment planning; they’re slow to change.) This document detailed an ongoing plot to boost dental production by promoting dental decay. For centuries dentists have been in league with bacteria! These supposed health care providers give unsuspecting children (and their chocoholic dads) ridiculous quantities of candy one night each year. Sticky caramel, pocket-producing tootsie rolls… dentists even sadistically named one brand of production-boosters “jaw-breakers.” Evil!

 

Tonight as I watch the beginning of the end of my daughters’ enamel, know that I’ll be looking for you dentists responsible for this. And I’ll be wearing a mask.

 

The Guessing Experts

I’ve spent the last half of my life researching something that doesn’t exist. True, I’ve chased a lot of white rabbits down endless holes. My Bigfoot hunt, search for sunken pirate gold, subprime real estate buying spree, and petition to ban mercury fillings were all wastes of time and money. Yet those were short-lived, or “stupid bachelor phases” as my wife reminds me weekly. I’m most disturbed by my 18-year obsession to become an expert on an elusive non-entity that earns real experts fame and fortune and NY Times columns and cable news shows. I want to become an expert on The Economy.

 

I’m not an expert in many things and I’m in good company. Flipping through Fox/CNN/MSNBC/The Daily Show, I’ve reached the conclusion that the real (paid) experts aren’t necessary experts either, not in the sense that they definitively know what’s going on in their area. Even my (former) mechanic couldn’t figure out what was wrong with my (former) car; hence my Prius purchase! It kind of puts the whole expert concept into question…

 

At Stanford I studied one of the most conflicted subjects outside of politics: Economics. My professors included former presidential advisor Paul Krugman, a formal World Bank president, an International Monetary Fund executive, a chief European Union economist, and somebody in the running for the Nobel Prize for Economics. These people mostly knew what they were talking about, and I mostly paid attention and mostly earned good grades. Even today I still diligently read economics textbooks and journals.

 

And I still don’t know what the Economy is.

 

I’ve never seen an economy. I’ve never touched one, polygraphed one, or given an economy a ride home after a long night of drinking. Yet everybody I know, even the experts on TV, seems obsessed with this invisible economy thing. It’s time to expose the economy for what it is: mass psychology and fortune-telling. To sum it up: The economy is only a concept that we non-experts (everybody) use to loosely understand how much money we’re making now and how much we can hope to make in the future.

 

Let me break down that scary sentence, word by word:

  • Concept–it’s not real; we’re putting a label on something we can’t really define (like “standard morality” or “reasonable standard of care”)
  • Non-experts–that’s all of us; as non-experts we aren’t really qualified in the first place to label or define it (unlike my ex-mechanic, who was supposedly qualified to define my ex-car’s problem)
  • Loosely understand–I don’t even understand why my Prius starts when I push the On button or why my wife gets snippy when I park the Prius on the lawn at 3am. Don’t expect society’s comprehension to be more coherent than my 4-year-old’s understanding of electricity
  • How much money we’re making now–The heart of the matter is Buying Power. On my salary can I afford food? New clothes? My own house? Kids? A Vegas vacation? A second Prius? A boat? A summer home? A private island? If the answer is yes, you’re happy and spend. If it’s no, you’re angry and curse the economy.
  • Hope–It’s not just a campaign slogan! Back to emotional psychology; do you feel lucky? Happy and lucky? Happy and lucky enough to spend money? Remember hope also has a downside called fear. When people are afraid, or are afraid others are afraid, they stop spending. It’s not rational; neither are humans (except my wife).
  • Future–This means tomorrow, in five years, in twenty-five years, and in retirement (not necessarily in that order). Our method for predicting the future ranges from computer modeling to ouija boards, and before you knock ouija boards remember those oh-so-accurate weather forecasters use computer modeling.

 

The economy is the sum of seven billion peoples’ blind guesses about their wealth some time in the foggy future. My wife and I can’t agree on our dog’s name (arriving next month); there will be world peace and trustworthy politicians before there’s any consensus on this nebulous economy concept. No wonder I’m afraid to eat Greek yogurt!

 

How does this apply to my dental friends, my dental friends ask. Your patients still believe in the mythical seven-headed economy. I recommend you look in the sterilization area and under the dental chair and promise the patient there is no economy lurking there. It’s just their imagination. Then remind the patients that:

  1. Their personal paycheck and bank account balance are all that matter, and they are coincidentally real.
  2. If the patient is employed and contributing more value than cost to the employer, don’t worry (and if not, remember deadbeat employees get fired even in gleeful economic times)
  3. If the patient doesn’t know where to invest any meager savings (the stock market is about where it was in fall 1999, the housing market still has enough traps to scare away Indiana Jones, and the shiny rock known as gold is in the middle of a 8,000-year bubble and still far below its 1980s price)… recommend investing in their own personal health! That never loses value and will be appreciated every time your patient smiles, eats, sleeps, and breathes.
  4. If the patient wants to save money, it’s much cheaper to get a $1,200 crown today instead of waiting for the condition to worsen and next year shelling out $1,500 for the root canal and then $1,400 for the crown (marked up because it now has a core buildup).
  5. Regardless of what the masses believe tomorrow holds, what is the value of being free of pain today? If your patients are willing to accept a little pain to save a little money, lower your fees and drill without anesthesia. That should prove my point in 5 seconds or less.

 

We all know those “health is priceless” sayings. At treatment planning time your patients need to be reminded that the economy boogeyman only exists in their nightmares, next to trolls and space aliens and tax collectors. Their health and happiness are much more tangible. It’s time to start putting their money where their mouth is.

 

 

“Insurance” math for patients who don’t like math or insurance

Last night at our dental study club I got on a rant. I rant enough  to be diagnosed with Tourettes, and last night’s hit a special nerve that caused more irritation than a knock-off mystery metal implant through the alveolar canal. Somebody brought up insurance–not real insurance, but dental insurance.

 

Dental insurance is NOT insurance. It’s so ridiculously not insurance that it deserves lame air quotes. Dental “insurance” is a very simple scam, far less complicated than the common Bernie Madoff ponzi or “you’ll get Social Security some day” schemes. Here’s how I explain dental “insurance” to patients:

  • If a  rock strikes my head (and many people are throwing strange objects at me now), Blue Cross says: “Marshall, go get yourself fixed. You pay the first $500 and your insurance will pay the rest.”
  • If a rock strikes my car, State Farm says: “Marshall, go get the Prius fixed. You pay the first $500 and your insurance will pay the rest.”
  • If a rock strikes my teeth, Delta Dental says: “Marshall, go get your teeth fixed. Delta will pay the first $500 and you pay the rest.”

 

That is not insurance! Insurance insures against something catastrophically expensive, like the night I had kidney stones and spent four hours in an ER bed with a morphine shot for a total of $16,500. Dental “insurance” gives patients a little bit of money to pay for a large bill, namely up to $1,500 if you have a “good” plan, or more commonly $1,000. What was the average dental insurance reimbursement back in 1967, you may ask? (Coincidentally I have that data.) It was $1,000. Also in 1967 a gallon of gas cost $0.33, an ounce of gold was $35, the median US house cost $16,500 (now the price of a 4 hour ER visit and some watered-down morphine), and a dental crown was $65. Today that crown is at least $1,000 (anything less and its core was a junked car battery in China two weeks ago). Everything else in the country has inflated in the last 44 years; gas is up 1,320%, gold 4,750%, homes up 1,495% even after the housing crash. Yet dental “insurance” benefits remain exactly the same.

 

Of course dental “insurance” premiums are up. So are dental “insurance” “company” profits and executive salaries. In 2007 and 2008 Delta CEO Thomas Fleszar brought home $5.5 million in salary and benefits–at least that’s what he reported to shareholders, and I have no reason to believe that a dental “insurance” executive wouldn’t be totally honest. And he deserves every million. Tommy Boy Fleszar and the rest of those geniuses running the “non-profit” known as Delta are all doing a bang-up job!

 

Let’s get back to the “benefits” of dental “insurance” (and I hate using air quotes, but I hate dental “insurance” more and it’s oddly “appropriate” in this case). As a small business owner (I do own a CBCT dental imaging center and consider its four employees my responsibility) I recently went dental “insurance” shopping. It was almost exactly NOT like shopping for a new car. I didn’t see anything I wanted and the sales people could care less what I bought.

 

As stated I can get at most $1,500 in dental “insurance” benefits. Does that mean they’ll cover all of my $1,200 crown? Of course not–that’s as likely as the DMV lady enjoying her job. Dental “insurance” will pay an undisclosed portion of each procedure, based on a top secret equation averaging the Usual and Customary Rates of dentists in my home of San Francisco, the nearby cow-town of Lodi, somewhere in eastern Kansas, and the US  territory of Guam. That’s why my dentist, with 25 years of experience and $30,000 of practice management software, has no clue what my dental “insurance” will cover. I finally figured out that if I get enough dentistry done, eventually my “insurance” will pick up about $1,500 of the bill. If I’m lucky.

 

For this “benefit” I pay only $175 per month. Let me save you a trip to the calculator. $175 per month, times 12 months, equals $2,100 per year I pay to my dental “insurance” for the awesome benefit of wrestling a maximum of $1,500 in dental reimbursement each year. That’s the kind of math that sunk the Greek economy. It also sunk my allegiance to dental “insurance,” and I’m now paying out of pocket (or in CEREC blocks… I “found” a few).

 

I recently cornered a mid-level executive from a well-known dental “insurance” company and asked a few questions. I can’t say which company, but I can say it rhymes with “smelt ya!” It went something like this (I changed his name to protect the guilty):

  • Me: “Why are my maximum annual ‘insurance’ benefits less than my annual premiums?”
  • Thief: “They’re pretty close.”
  • Me: “No, I lose about $600 per year if I max out my benefits.”
  • Thief: “Uh… most clients don’t do that much math.”
  • Me: “I multiplied my monthly payment by 12. It’s not quantum physics.”
  • Thief: “Still, most people don’t think that way.” (see my We’re Stupid post)
  • Me: “That’s not much of an answer… why do I seem to be losing so much each year.”
  • Thief: “[Smelt-Ya] is a big company. We need to cover overhead expenses, and shareholders.”
  • Me: “Your executives and shareholders are doing well?”
  • Thief: “Very well! We’re a solid company.”
  • Me: “But wouldn’t I–and all of your ‘clients’–be better off without you, just pocketing our $2,100 and paying your ‘up to’ $1,500 worth of coverage?”
  • Thief: “Like I said, most clients don’t do that much math…”

 

My We’re Stupid blog post is becoming more all-encompassing, and not just because we’re approaching an election circus. Dental “insurance” is only for people who are really bad a math. Dental “insurance” should be sold at 7-11 with lotto tickets. However, there’s a reason why it cheats all of its clients. With normal insurance, like fire or auto theft, the insurance company charges everybody a little and then gives payouts to the few people who suffer those events. I don’t know anybody who has had a house burn down or a car stolen, yet I (and all of my friends) have home fire and car theft insurance.

 

Our mouths are a different story. We use them every day, and humans (for the first 99.5% of our existence) didn’t usually live past our 40′s. Now we do… but were our teeth made to? Were our teeth made to withstand chewing ice cubes and opening beer bottles at parties and nail-dissolving soft drinks and hard candy we sadistically label jaw breakers? Our teeth break. And they’ll continue to break, annually, regularly, completely, either by fracture or decay. And we’ll need some level of dental care every year. Dental “insurance” companies can’t spread the risk when there’s a better than average risk that we’ll all need a lot of expensive care. It’s like a life insurance company targeting a leper colony. Bad business… unless you raise the annual rates to exceed the annual coverage, and hope nobody does the math.

 

I just did the math for you, and it isn’t pretty. Neither is dental “insurance.”

Scroupon, the practice drug

A few of my dentist friends have experimented with Groupon, or another copycat mass discount site. A few dentists have also experimented with cocaine. Both brave groups experienced the same result: everything sped up for a period of time, yet the doctor ended the ride feeling exhausted, broke, and foolish.

 

For those of you who don’t know, here’s how it works. Cocaine floods your brain with euphoria-inducing chemicals; you feel extremely focused and think you accomplish more than ever before. Groupon floods your practice with patients; you feel extremely productive and think you are earning more than ever before.

 

Then reality kicks you in the crotch.

 

After either rush you’re exhausted (you worked so hard) and depressed (you needed something to help you) and broke (it’s an expensive habit) and stupid (no elaboration needed). On the cocaine side, it’s expensive and stupid. Let’s face it; illegal drugs aren’t mixed by university-educated bio-chemists using regulated material, and you’re not taking a potentially fatal heart-accelerant in physician-prescribed doses. Cocaine is coo coo for cocoa puffs crazy stupid.

 

So is Groupon. During the promo period you’re flooded with new patients… who are all there because your services are discounted, not because your services are excellent. These are the price-paranoid who would accept used cotton rolls if that would further reduce their cost. True, a few of these discount-addicts might hang around after the Groupon special ends and your regular fees surface like the shark fin on Jaws. But don’t count on it.

 

“But during that Groupon rush won’t I fill my schedule and increase my profitability?” you may ask. Yes, you will be busy. Yes, your schedule may burst at the seams. No, you won’t be profitable. You offer a service through Groupon at a steep discount, so your fees are already lowered. Then your flood of rent-a-patients pay Groupon for the service, Groupon takes a health percentage (20-50%… they aren’t a non-profit or charity), and Groupon pays you the remainder. In short, you earn maybe half of your standard fee.

 

“But half is better than nothing, right?” Wrong! What’s your overhead? (If you don’t know, getting hooked on cocaine or Groupon is the least of your worries.) Most dentists operate at 60-70% overhead, meaning they take home 30-40% of their production. Reduce the fee for a service by half with Groupon and you’re actually losing (paying out of your pocket) 10-20% of the cost so the Groupon groupies can enjoy it. Each Groupon junkie patient costs you money; it would be cheaper not to see them. If you’re feeling charitable, work at a clinic on Friday. I’m looking at a Groupon deal now from one adventurous dentists, offering x-rays, a new patient exam, and a prophy for $49 (discounted 84% from $300). Sadly the dentist probably gets $15-20 for her time after Groupon takes its cut. The minimum cost of turning over an operatory is $30, and that doesn’t include staff time…

 

In addition, that Groupon horde is filling your schedule and crowding out some new paying patients. Then the special ends and the horde leaves like those estranged in-laws who stay at your house an extra week and eat everything, drink everything, borrow money, and pilfer a few souvenirs. As a final insult, like the moocher in-laws leaving dirty dishes under your bed, Groupon groupies are much more likely to place negative Yelp and online reviews than their full-price counterparts (www.nytimes.com/2011/10/02/business/deal-sites-have-fading-allure-for-merchants.html). So these discount donkeys cost you money, crowd out long-term patients, trash your reputation, then leave when the free ride is over.

 

You do not want patients who trust their health and happiness to the lowest bidder. Trust me on this. These are also the patients who don’t make their appointments, don’t pay their bills, and don’t value your time… until they’re in pain. Then they hound you and your staff as if you were personally responsible for force-feeding them cigarettes and Snickers and Sprite while ransoming back their floss and toothpaste (and they’re too cheap to pay the $4.95 ransom). These patients devour your time, profitability, and happiness—and they keep coming back for more. Treat them as you would flesh-eating zombies; run! If you are determined to speed things up, maybe you are better off trying cocaine.

  

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