Modern Case Presentation
There are six steps to modern case presentation. These six steps are geared to giving the consumer an “experience” and reason to stay in your practice.
Step 1: Condition: This is defined as signs, symptoms, and chief complaints.
Step 2: Location: This is where you visually show and tell your patients conditions with technology.
Step 3: Treatments: These are the basic procedures you learned in dental school.
Step 4: Materials and Procedures: This is the where you differentiate modern products and services
Step 5: Treatment Plan and Finances: This is where you combine the services with their associated fees, and commit the patient to the work.
Step 6: Appoint: This is done only after financial arrangements have been made.
Now for the shocking discovery; This six step process in modern case presentation is identical to something that is taught in business schools all across North America. It’s called a “sales cycle”. Keep breathing, you’re going to be just fine as you realize that you actually have been a sales person throughout your entire dental career.
The six steps of a “business” sales cycle are as follows:
1. Introduction (just like introducing your patient to their condition)
2. Gain favorable attention (sort of like getting your patients attention by showing them where their condition is located)
3. Create the need: focus, magnify, commit (hmmm, like creating the need for treatment)
4. Relate the features to the need: differentiate (wow, this is just like relating the features of modern technology to the needed treatment)
5. Close the sale (well, this is what we do when we show the patient the treatment plan and put the financial arrangements into place)
6. Follow-up (we call this appointing the patient)
Now, lets go into depth with each step to modern case presentations.
Step 1: Condition
Before you even begin your exam, you have to assess the patient. We do this by observing the following: Signs, Symptoms, and Chief Complaints. A “sign” is what we see clinically. A “symptom” is what your patient feels. And a “chief complaint” is what the patient feels is most important to them.
Often times I see practitioners diagnose the “needs” of their patients, and never ask them about their “wants”. This is where very caring dentists end up treating patients with disease, earning several hundred dollars every day, when tens of thousands of dollars walk out because they failed to listen to the patients chief complaint of “dark ugly teeth.” Ask the patient how they feel, and listen to their concerns.
When a patient comes in for a comprehensive, periodic, or limited exam, it’s up to us to diagnose abnormal conditions. Over the years, I have seen a wonderful increase in diagnostic capabilities. Not only is technology giving us better tactical tools for diagnostics, but the profession as a whole delivers more thorough exams.
When that exam begins, you are on a hunt for anything outside of normal limits. DO NOT be afraid to address those ill-fated findings with your patient. Promise yourself right now that the “watch” button or chart entry will be reduced to near nothing. Use action words and phrases that consumers can understand such as: unhealthy, serious, will only get worse, infection, and others. Communication is everything, so make sure you are speaking “patient language” and not scientific language.
Your training, especially when starting your practice, will not be the same training and expertise you will grow into mid-way through your dental career. Just do your best, and keep doing your best. I’ve noticed that most diagnostic skills are like a bell shaped curve. We get out of school and know just enough to get by. About mid way through our career we are extremely competent. Then age sets in and we lose the drive. This observation is supported by looking at the average age group at most continuing education courses. Keep the drive!
Step 2: Location (Show and Tell)
Patients who religiously brush, floss, and see you twice a year have no respect for our job security and usually have no conditions to report. However, thank goodness for the other ninety plus percent that have better things to do than take care of their oral hygiene.
Once you find one or more conditions, it’s time to tell your story. Early in my career, this consisted of multiple mirrors, light, and weird angles. Not any more (again, one more reason to go digital). This is why I went completely digital in my office back in the early 90’s, and why Dentrix had me lecture for them. For years I have had the ability to place a camera in my patient’s mouths and show them their conditions in living color. Nothing, and I mean nothing, is more powerful than the visual. I was just reading an article in a major publication where a younger practicing colleague had just experienced his first month with digital imaging. He couldn’t believe how easy it was for his patients to accept treatment when they saw their own dental misfortunes. I love seeing and reading about this excitement within our profession.
I want you to know how easy it is to show patients their radiographs and color images on color monitors. These images are stored right in the patient’s charts with most of the nations leading practice management software. Patients are visual. Just look at what they wear, how they style their hair, or what they drive. They want to be informed as to their conditions, and having the capability to show them on a flat panel screen definitely gets their attention.
I’m always amazed at the words and phrases that come from my patients when I show them their condition. “Oh, that’s gross! Turn it off,” or “Is that really in my mouth?” Little five year old Suzy in the chair with mom looking at a pending pulpotomy on the monitor: “Suzy,” mom threatens, “you need to brush better or you’re going in time out.” Suzy says, “But mom, you took the toothpaste and the floss out of my bathroom and haven’t given it back.” I love children because they remind us of our real duties in life.
Show your patients the “what” and the “where”.
Step 3: Treatment for the Condition
My favorite patients are those who ask the following question after showing them their condition: “How and when can we fix it?”
The next step is to show your patient how you will correct the problem. Such education can be done with several tactical tools such as procedure videos, still images, even hand held models. In my practice, once again, we continue to move towards technology and utilize our web based system Treatment PRO to give treatment knowledge to our patients. Although it’s true that models are good for patients to touch and feel, I always hate it when parts such as crowns or implant pieces end up lost. Video and images are fast, clean, and keep our office uncluttered with models and tacky posters. I look forward to the day when holographic technology enters dentistry. I hope I live that long.
We are very fortunate to live in this day and age of dentistry for this very simple reason; when we show how we are going to treat a dental condition, we are confident that it will be fixed with an extremely high success rate. Open your mouths, share your knowledge, teach your patients as to how you will treat their problems, and allow technology to document everything. Images and diagnostic notes not only protect us from the evils of law firms, it includes our patients in their treatment like nothing we have ever had before.
I want to emphasize the importance of giving patients options where options can be given. When we think of treatment options, most of us have been trained to differentiate as follows: crowns are either gold, PFM, or all porcelain. Fillings are either silver or white. Non surgical, periodontal therapy includes scaling and chemotherapies. These are differentiations that we see with our CDT codes from the ADA and are confirmed by insurance companies. It’s time to think outside the box because that is where technology has taken us.
Step 4: Materials/Procedures-Trading Up in Dentistry
After we have explained to our patients how we are going to treat their conditions, we show choices where choices are available. We differentiate those choices, and tell our patients the associated cost to trade up to more hi-tech products and services. Patients appreciate knowledge and choice, and are willing to pay additional fees for those choices.
In the many years I have been in practice I have seen an amazing explosion of technology in the form of equipment, materials, and procedures. I have also seen an increase in the cost of doing business. What I currently spend in laboratory expenses is not what I spent years ago. The price of supplies and laboratory expenses has more than doubled, as has the cost of everyday equipment. There is also the needed equipment to provide hi-tech procedures and services. While digital panoramic machines have experienced a cost reduction of fifty percent, they are still more than double what traditional machines cost.
The million dollar question is this: have insurance companies kept up their reimbursement fees equal to the increased costs of doing business? Of course not! I don’t believe I have even had an insurance fee increase in the last three years. So how can I order and offer more expensive services and products to my patients when it cuts into my profits dramatically? The answer is DIFFERENTIATION, and CHARGE FOR IT!
Let’s look at crowns. We all know that PFM crowns are significantly less expensive than all porcelain crowns. Most of us want to place PFM crowns in our patients mouths for several reasons: they are less expensive; We are not reimbursed enough from third parties to justify offering all porcelain crowns; we had bad experiences with all porcelain crowns fracturing in their early existence; we hate bonding crowns; we really don’t know anything about all porcelain crowns because we haven’t taken the time to learn, and so on.
What I have never understood is why you don’t charge your patient for any “added value service”, for any hi-tech product, procedure, or any other service that goes above and beyond what has been the accepted perceived standard in our industry. Who in the world told you that you could not make a profit for value added services? Why do you allow your patients and yourselves to be governed by such nonsense?
For example, I was lecturing on trading up in dentistry over a year ago. My presentation included teaching colleagues and team members about offering patients choices in crown products, and charging an additional fee for higher end, cosmetic value added service. To help you understand this more, think about one of my favorites, an Empress Crown by Ivoclar. Most of you should be aware that you can order this crown from labs all across this country from roughly $100 to $350 per unit. If our CDT code 2740 is set at one fee, which is what insurance companies do, I already know which lab you’ll be ordering from. But you and I also know that there is a big difference in porcelains and translucencies from one technique to another, and you get what you pay for.
But if your patient is taught the difference in porcelains, techniques, and coping types, which crown would they choose? What if the difference between your current labs basic all-porcelain is $150, and the price for their more hi-tech crown is $250. Should you give your patient the choice? Should you charge them for the difference? Consider your choice from a business perspective and do what every other business (including hospitals) do. Not only should you charge the difference, but actually mark it up! That’s right! Charge an additional $200 for the upgraded product. It’s alright to do what other businesses do. You really don’t have to do dentistry for free.
As I was giving this lecture, some poor “I know everything” office manager raised her hand and belted out, “You can’t do that; it’s illegal!” I know how she felt. I felt the same way for years, which was until I had an epiphany of thought while listening to Gordon Christensen talk on operating costs. She had fallen right into my trap. I asked her to name the insurances her office took, and then asked her to pick one of them for us to call. She thought I was crazy, but we called anyway. The question was asked like this, “I have one of your insured clients in my office that needs two posterior crowns. We would like to place a product called Lava on both of those teeth. The problem is that Lava costs us significantly more than our regular all porcelain crowns. Can we charge the patient, your client, an additional fee to cover our additional lab fee and liability for such a restoration? Of course we will disclose to the patient that this value added service is an additional cost to them and not a covered benefit from you the insurer?” The answer was “absolutely.” She continued to tell us to read our contract because a clause in the document vaguely states that already. It was not my intention to insult or embarrass that office manager, but I will be honest, I did enjoy it. I enjoyed the experience because closed minded team members often cost us more than we know. Pull out the contracts and read them.
My next question to the audience was “how many of you have read your PPO contracts cover to cover and understand them?” The answer is always the same: read what? I'll say no more!
When we trade up in dentistry, offering more expensive alternatives and high tech procedures to our patients, do not just increase your fees by the cost difference--raise it for a profit. Do you believe Gap only raises their fees by the increased of cost of goods? Do you believe Delta Airlines only raises their fees by the ten cents per gallon increase in fuel? Our businesses are no different. Why do you think hospitals itemize every little thing when you visit? Do not just raise your fees accordingly; create new codes, descriptions, and fees to account for upgrades. Most practice management software allows you to do this. Insurance companies are trying desperately to bundle our codes and fees. Don’t let them. Constantly let them know that you will not allow this to happen. Chances are they will allow you to charge for it. Push back hard.
To drive my point home, you need to know that in my practice resides two patients that are upper level managers from two of the major insurance players found all across this country. Both of them have personally needed crowns, fillings, and other procedures that we have charged additional fees for. Both have upgraded and paid additional fees for more expensive products and services, and have appreciated the fact that I have given them that choice. Many of their co-workers have joined our practice over the years with the same appreciation of choice. No, it is not illegal to offer value added and cosmetic services to your insured patients. Yes, you can turn it into a profit center. Stop beating up the insurance companies for your own lack of high tech knowledge. Insurances can not dictate treatment to your patient, and value added service is treatment at its best.
So what are areas of choice we can give our patients? Consider crowns and bridges as these lab fees are all over the board. I offer PFMs, gold, and all porcelain restorations for posteriors. More specifically, Cercon and Procera (Lava is a good choice also) for posteriors. I like Eris for bicuspids and anterior teeth, when strength and esthetics are needed. Empress is my favorite with a cut back technique for cosmetic cases. Need to cover a dark stump and want ultimate cosmetic results? Captek or Bio 2000 is my tool of choice. For short span bridges where esthetics are a concern, I prefer Eris. Posterior bridges with long spans go to Cercon or PFM.
As for composites, we all know that 3M’s Filtek Supreme is one of the most expensive. I only use it when a patient wants to upgrade to micro-hybrid multilayered technology. When they don’t, I use Amelogen plus from Ultradent. I also use Esthet-X for more opaque shaded teeth. Filtek is sometimes too translucent. The value added service is in the layering technique, and in the technology of the material. I can’t wait to see what the future brings. Ten years from now these materials will probably be obsolete.
Another area of choice is in whitening. If you use Zoom or its equivalent, you should charge more than using trays. If you use a laser to remove decay, charge an additional fee by differentiating your equipment and service. If you do laser therapy in association with periodontal therapies, create a code, description, and value added fee.
Other dentists often ask me, “What about our fee-for-service patients?” Charge them an additional fee too. How in the world will any of your patients appreciate what you do for them if you don’t explain to them what you do and charge for it? It’s like that Amoxicillin 500mg capsule (just one) that costs the hospital .08 cents to purchase, yet costs you, the patron, $9 dollars on your bill. The explanation is that the pharmacist has to take the time to make sure you won’t die from taking it, the nurse has to feed it to you, and the administrator has to track it. It’s all about added value service. I just believe we do a better job of it, and we should get paid for what we do. Hospitals bill insured and non-insured the same way, and so should you. My fees always range in the seventy-fifth percentile. Adding value added charges rarely take my fees beyond the ninetieth percentile when it comes to traditional paying patients.
Step 5: Treatment Plan/Financial Options
No patient needing treatment should ever leave your office without a treatment plan, supporting documents, and financial arrangements in place. My practice has very unique business folders that these documents go in. These folders are marketing pieces that are branded to our practice, and have generalized information about us on them.
Every legal aged patient signs a financial policy form that explains their financial obligation to our office. They understand that payment is due at time of service. We simply do not carry accounts. For our insured patients, co-pays are due at time of service, with the understanding that it is only an estimate. If a patient needs financing, then Care Credit or some other form of financing is available to them. If they do not qualify for Care Credit, and they can not come up with financing, we simply do not do the work.
Do not deviate from your financial policy unless it’s your mother-in-law!
Step 6: Schedule
Patients get scheduled only after financing is in place. There are very few things that can ruin a schedule like having to turn a patient away, after they have been blocked out for several hours, because they can’t come up with their co-pay or full payment for services.
Next, schedule for the day. What I mean by that is you should have daily production goals. If there are holes in your schedule for the upcoming day, fill them. Once you have worked a day with holes in the schedule, you can never make up that lost production ever.
With digital technology, it’s easy to schedule hygiene appointments every thirty minutes for every three patients. On the third patient, give them the whole hour. In other words, you would have a patient at 8:00am, one at 8:30am, one at 9:00am, and the next hygiene appointment would be at 10:00am. This is called scheduling in triplets, and it works well.
Do as much production as you can in 3.5 hours. Work by quadrant or side. The reason I like to hold it at 3.5 hours is because that is the amount of time you can reasonably keep a patient anesthetized without too much jaw discomfort.
And the most important thing about the day is really a marketing play. Call every patient at the end of the day who got a needle stick. See how they are doing. This act of kindness goes a long way with patient care.
Dr. Rob…
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