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What Do the Findings Say? The 2023 Orthodontic Practice Survey Deep Dive · Orthodontic Products Podcast

0:04
Alison Werner: Hello and welcome to the Orthodontic Products
0:06
podcast. I'm your host Alison Werner. Today we have back with
0:09
us Dr. Roger Levin at the practice management consulting
0:12
firm, Levin Group. He's here to help break down the findings of
0:15
our third annual orthodontic practice survey. Dr. Levin,
0:18
great to have you back.
0:21
Dr Roger Levin: Alison, it's wonderful to be back. I love
0:23
doing the survey with you. I'm glad it's our third year and I'm
0:26
looking forward to our conversation today.
0:29
Alison Werner: Great well, as I said, this is now the third year
0:32
and the survey asked orthodontists to tell us how
0:35
their practices fared the previous year. So we're gonna be
0:37
looking at 2023. Before we dive into the details and get into
0:41
your advice to doctors and staff who are facing some of the
0:44
challenges reported, what was your overall assessment about
0:48
how orthodontic practices fared as businesses in 2023?
0:52
Dr Roger Levin: Yeah, if I had to pick one word, and I like to
0:54
do that, I would say stability. Things were fairly stable. We
0:59
had a pandemic, we had a rapid rise in overhead in 2022, the
1:05
biggest rise in overhead in any single year, in the last 40
1:09
years. And in 23, it went up a little bit more. But production
1:15
in practices in 22, and 23 was fairly stable, we're going to
1:19
see that it's down a little bit. It's not all it's not gloom and
1:22
doom. But I would say it was a year of stability that this is
1:26
the first year since 2020, that we are back to a more normal
1:30
landscape. normal scenario, we don't have any huge problems,
1:35
even the economic problems are limited, although the fact that
1:39
people are seeing some issues with their everyday goods like
1:43
eggs and milk and things like that where we're seeing a little
1:47
bit of a production drop. But I want to be positive. Any
1:51
practice that looks like right now can use the year 2023 as a
1:55
launching pad to do really well. That's great.
1:58
Alison Werner: Okay, good. Okay, so let's start by going through
2:02
some of the findings. And let's start by talking about
2:04
production. How to 2023 stack up against 2022?
2:09
Dr Roger Levin: So I love data and statistics. And you can make
2:12
them sound like a lot of different things. The fact is,
2:16
that production overall dropped in orthodontics in 2023. Now, as
2:21
I said, it's not gloom and doom, it dropped by about 4.7%. So
2:26
nobody has to panic, if I start panicking, so I don't panic, but
2:31
I would panic. When I hear me to practice this down 10% or more,
2:35
if they're down 10% in a year. Any of you listening to this,
2:39
that's when you really need action and help and turn around.
2:42
You don't want that to get worse. I'm not real concerned
2:46
about the 4.7%. And I'm not not concerned because it's a one
2:51
year data point. The question as I wrote in the article that
2:54
you'll be publishing is, is this the beginning of a trend, I've
2:59
talked a lot about orthodontics, getting a little bit more
3:02
competitive. I mentioned in the article, one of the biggest DSOs
3:07
in the country now offers orthodontics through its general
3:10
dentists at $1,999. They have their own branded aligner. So
3:15
whenever you see competition, you've got to pay attention to
3:17
see how you're stacking up. The one comment I make always is
3:23
your goal is to increase production every year. It
3:26
doesn't have to be by a lot. But if you can do that, if you can
3:29
increase production every year, you are going to be somewhere
3:32
between good and great as a practice.
3:35
Alison Werner: Okay. And you talked a little bit before about
3:38
how we're kind of stabilizing in terms of you know, those those,
3:42
you know, different those unique years of 2021 2022 because of
3:48
the pandemic and everything. But one of the things that is
3:52
happening or kind of looks like it's happening in 2023 is that
3:55
that pent up demand due to the pandemic and all the savings
3:58
that was built up is kind of disappearing, and we're kind of
4:01
righting the ship basically,
4:03
Dr Roger Levin: Right. If I were an economist looking at
4:05
orthodontics of the last few years, it would be impossible to
4:09
get a handle on it because the pandemic was so unusual. In 21,
4:14
the pent up demand many of our client orthodontic practices had
4:18
record years even though they were shut down for four to six
4:21
weeks. And they were exhausted by the end of the year. In 2022,
4:26
overhead skyrocketed and there was still huge pent up demand
4:30
coming in, people deciding to have ortho. What what happened
4:34
to some degree was that people weren't spending money. So they
4:39
were sitting at home saving. They weren't spending it on
4:43
travel, luxury, entertainment or restaurants. So there was all
4:48
this extra money. It wasn't the, you know, 12 or $1,400 they got
4:52
from the government that let them do it though. It was all
4:55
the savings. But by 23, we know that savings is disappearing
5:00
right now. How do we know that because credit card debt now is
5:03
back to an all time high, when nobody, nobody puts interest on
5:07
their credit cards if they have discretionary income to spend.
5:11
So we have definitely bumped up against the excess savings that
5:16
people could use for ortho. And now we're back to doing
5:19
orthodontics only for people that really want it, not people
5:23
who in the past wouldn't have gotten it, but they had extra
5:25
money so they decided to get it. So I think that is a definite
5:29
contributory factor to the slight drop in production in
5:34
2023.
5:35
Alison Werner: Okay, so keeping that in mind and kind of some of
5:38
the other economic headwinds, what strategies can practices
5:42
employ to continue to grow that production?
5:45
Dr Roger Levin: Well, here's what's interesting, you know,
5:47
I'm 39 years into this job. So I'm, I'm almost at halfway in my
5:51
career at this point. And, and I love I love looking at the
5:57
numbers over the years because it tells us so much. The average
6:00
practice in 2023, produced $1,535,000 and change. But we
6:09
know because I've built these models over and over and over.
6:12
And we've worked with over 4700 orthodontist since 1985,
6:17
worldwide, mainly US but worldwide, we know that any solo
6:23
orthodontist can produce $2 million a year in four days a
6:26
week, comfortably. We see we see people, a small number, but we
6:30
see people that do that in three days a week. You know, ortho has
6:33
what I call the volume factor. Unlike the rest of dentistry,
6:37
you can put a lot of volume through. And later probably
6:40
toward the end, if I'm anticipating your questions, I'm
6:44
going to talk about how you might be able to double or
6:46
triple the orthodontic practice without working one more minute.
6:50
But for now, the main point is there's a big gap a half a
6:54
million dollars or 25% between where the average practice is
6:59
and where it can be. The other way to say it is most
7:02
orthodontic practices could easily increase production by
7:07
$500,000 if they have the right strategies and referral
7:10
marketing in place, and that's an enormous, enormous
7:14
opportunity.
7:15
Alison Werner: Okay. Okay. So let's go back and talk about
7:19
practice overhead and what the findings for this survey
7:23
reported or showed, and I know it said you wrote that overhead
7:27
was on the rise. So yes, what did what did practices report
7:31
for this year?
7:32
Dr Roger Levin: Yeah, well, I'll start with the good news. The
7:33
good news is that the overhead rise was pretty small in 2023.
7:38
It went up about eight to 9% in 22. It went up another one to 3%
7:45
in 23. Not not bad, it's slowing down. You know, based on what I
7:51
know about production, and my career has been dedicated to
7:55
identifying systems and strategies to grow production.
7:59
Based on what I know about that, which is fairly deep, we can
8:03
make up for a one to 3% overhead increase in production in any
8:08
given year. But 59% of the orthodontic practices survey did
8:13
report, they had higher overhead and only a smaller number 13%
8:19
reported that overhead had actually gone down. So it's not
8:23
a surprise, you know, the cost of everything is up. And the
8:27
increased costs from 22 due to supply chain due to staffing
8:32
heavily, I'll get to staffing in a moment, those costs are not
8:35
going to come back down. So we must increase production to
8:39
offset them. What I teach, which is very well proven at this
8:43
point, is lowering overhead is good, but you can probably only
8:48
lower it about three to 4%, maybe five or six in rare cases.
8:54
But you know, if you've got waste, you need to eliminate the
8:57
waste. The problem is overhead reduction is finite, you can
9:01
only go so far. And once you've done it, you're done. You can
9:03
only fire an assistant once can't fire her twice or three
9:07
times. If you're trying to save money, but production can
9:11
increase infinitely it can go up two percent 5% 20%. Again, most
9:17
orthodontists underestimate their real potential, which
9:21
unfortunately means they're not as protected, that profit goes
9:26
down. The problem is if overhead goes up, and it's not offset by
9:30
production, at least equally, profit goes down. So we're
9:33
seeing a lot of practices that even increased production and
9:36
profits still down three or 4% a year. So what you want to do is
9:41
understand that lowering production is a limited gain
9:45
rate. I'm sorry, lowering overhead is a limited gain.
9:49
Raising production is an unlimited gain. You can grow at
9:53
12% in a year or a lot of our clients grow at 18% the first
9:57
year and the second year 18% each. then that's going to
10:01
offset any two or 3% increase in production with a 13 or 14 or
10:07
15% increase in profit. So, overhead's going up, it's going
10:12
to stay up. Why? Staffing is a crisis. It's a different podcast
10:17
for us to do someday, Allison. Yes, I get every dentist I talk
10:22
to every new client that comes in is struggling with staffing.
10:27
And I could I could list the top 10 negative factors of the
10:31
staffing situation today. Bottom line, we've got a shortage. It's
10:35
not going away anytime soon. It, I think it's with us for at
10:40
least 10 years, and I can't see beyond that. So we need better
10:43
systems, smoother running practices, more technology to
10:48
offset labor. But in the meantime, staffing is up about
10:51
10%. And that means production has to go up at least 10% to
10:58
offset the staffing increase. It's not going to come back
11:01
down. So if anybody's waiting for it to reverse, it's going to
11:05
go up more, it's not going to come down. We have some real
11:08
challenges in staffing, which are number one, there are people
11:12
who are afraid to work in medical and dental because of
11:16
they're still worried about COVID. I know most people are
11:18
saying, oh, it's over. But there's still people who are
11:21
worried. Number two, a lot of people now want to work from
11:25
home at least three days a week, those people are not taking jobs
11:29
in orthodontic offices. So they're off the table. And
11:32
number three, we had about six to 7% to 8% of our orthodontic
11:37
staff retire at all ages, they just decided that they're done.
11:42
And I guess unless they become financially challenged, they're
11:46
not coming back. So we have a smaller labor pool. We're hiring
11:50
less experienced people that need training, and the costs are
11:54
way up for all of that. And if you look at minimum wage, now
11:58
there are articles every day now about minimum wage in
12:00
California. It'll be the rest of the country, $20 an hour for
12:04
fast food. That's a that's a 25 to 50% increase in labor. We're
12:12
only a 10% in orthodontics right now.
12:15
Alison Werner: Okay. Okay. So that it's time to start figuring
12:19
out other other strategies. Oh, yeah, absolutely.
12:21
Dr Roger Levin: Again, you want to we can talk about this later,
12:23
if you want. But you want to keep the staff you have that's
12:26
the best way to avoid all the other pain?
12:30
Alison Werner: Yeah, well, I think that the message here is
12:32
we're going to do a separate episode on just staffing. So
12:35
look forward to that. Stay tuned.
12:37
Dr Roger Levin: I've been doing a lot of work in that area,
12:39
because we have to.
12:40
Alison Werner: Yeah, yeah, I know. Yeah. Well, let's talk
12:43
about patient volume and what the survey found, because that
12:45
does tie in to dealing with, you know, countering overhead, you
12:49
do need to get that production up. So you need that patient
12:52
volume to be up. So was it up? Or was it down?
12:54
Dr Roger Levin: Well, it 72% said it was the same or up?
12:59
Which is interesting, because if production's down, you know,
13:03
little under 5%, how is volume the same? And the answer is
13:09
several things. Number one, the volume of referrals does not
13:13
always reflect the volume of starts. So referrals may have
13:18
been steady, and we're going to talk about that I know. But the
13:21
starts may be down we have more shopping, we have more options,
13:25
we can go to a DSO staffed by general dentists, we can go to
13:29
general dentists who are doing aligners. And that's really
13:33
interesting when we get to where referrals are coming from. This
13:36
was a really interesting finding. But six, it's
13:39
interesting that 72% said that their volume was about the same.
13:45
So I found that interesting. But in reality, their volume wasn't
13:50
rising. And it may be that if you don't have more patients, a
13:55
higher percentage converting to starts, then you need higher
13:58
volume to make up that difference. So the fact that we
14:01
don't have higher volume is the thing to really pay attention to
14:05
don't get comfortable saying, Oh, I've got the same number of
14:08
referrals or consults. And by the way, it's not in this
14:12
survey. In another look, we found that up to 16% of parents
14:19
or patients that call an orthodontic office, never make
14:22
an appointment for a consult. Nobody tracks that. So we didn't
14:26
ask it in the survey because nobody would know. But we did
14:28
take a hard look at a large number of client offices and new
14:32
clients so that it was random. And we found that when we start
14:36
with them, many as they start tracking, have a number of calls
14:40
coming in that do not schedule for consults. And they're asking
14:44
questions like well, how much is ortho or how long will it take
14:47
or do you do this type of procedure? The front desk staff
14:50
are not well trained to handle those questions. We need
14:53
scripting for that.
14:55
Alison Werner: Okay, so that they the inquiry from the from
14:58
the prospective patient snd our consumer is changing.
15:00
Dr Roger Levin: Right and the front desk staff and they're
15:03
very nice people, I have great respect for them. But they are
15:07
only good right now at the standard basic new patient
15:07
Alison Werner: Right? It sounds like it, especially as you know,
15:10
calling and wanting to make an appointment. They're not good at
15:14
building, it's not something they can learn it, they can
15:17
easily learn it. Yeah, but they're not good at building
15:20
value in the mind of a patient that has questions. So every
15:24
practice should at least write scripts for the top six or seven
15:28
questions that you get from a new patient call or this is this
15:32
is now a good idea. In the future, it's going to become critical.
15:38
consumers now can, to a certain extent can better comparison
15:43
shop, even just online to get you know, what are the average
15:46
prices in my region? Or, you know, they do have those ads
15:49
from those DSOs? Like Aspen. Yeah, it's freely advertising
15:53
very publicly advertising what they charge. So
15:55
Dr Roger Levin: we've gone from years ago saying things like,
15:57
well, we'll tell you that when you come in, and that work back
16:00
then to focusing on value building, the new patient call
16:06
is the first step of what Levin Group calls the new patient
16:09
experience. And if you don't get that, right, you have missed the
16:14
boat in a big way. And your start rate, they may not come
16:17
in, they may not show up. And they may not accept treatment
16:20
all higher, if you don't have a great new patient experience and
16:24
value building process in that first phone call. So the front
16:28
desk person has to think of themselves as the first
16:30
treatment coordinator they meet. And then they come in and they
16:33
meet the second treatment coordinator. That's how I view
16:36
it today.
16:36
Alison Werner: I think, yeah, that actually that actually
16:38
makes a lot of sense. So. Okay, well, so let's break down the
16:43
sources of new patients. What were, what did respondants say?
16:47
Dr Roger Levin: Yeah. So I want to warn everybody, there's a lot
16:47
Yeah. So what's your overall takeaway from this information
16:50
of bias out there about referrals from general dentists,
16:52
about referral sources?
16:53
we, you know, and I want to warn you, this is data. This is not
16:57
my opinion. But this year, it was a change as the number one
17:01
source of referrals. The number one source was from referring
17:05
doctors. And it's this is really interesting, because what we
17:09
show in our surveys is that approximately 3.6 billion with a
17:12
B, $3.6 billion of revenue is referred each year from general
17:16
practices to orthodontists. Now, may have been more five years
17:20
ago, we're only in our third year Alison of doing this with
17:24
you. So we don't really know. But the number one source of you
17:28
know, 38% of patients were coming from referring doctors.
17:31
So I, I want to be careful because that's the kind of we do
17:35
we have a whole program and referral doctor marketing, and I
17:39
don't want to sound like I'm leaning towards something,
17:42
because that's what we do. This is complete data completely
17:46
objective. But I encourage people build your referral
17:49
marketing also, for referring doctors. Don't say they're doing
17:53
all the ortho or they don't refer. We find a lot of new
17:57
clients who tell us that they're not getting referrals from
18:01
general dentists because the GPs are doing all the ortho. We find
18:05
two things. One, they're not getting referrals, but the GPs
18:08
are not doing all the ortho they might do some, they're referring
18:12
it to other orthodontists. And a year later, were getting lots of
18:17
referrals from referring doctors, they had just never
18:20
focused on it. And since it didn't just automatically
18:23
happen, or it didn't happen after a few strategies, they
18:27
decided, well, this isn't going to work, and they gave up on it.
18:31
Well, if you're not doing anything, there's a very good
18:34
chance you won't get referrals from referring doctors. I'll
18:38
read you the list, which I have in front of me after after
18:42
referring doctors, number two was referrals from existing
18:45
patients. So a lot of dentists think they're just orthodontists
18:49
rather think they're just so well known in the community. And
18:53
they may be, but it's really referrals from the parents and
18:57
patients that are a huge segment. So you don't want to
19:00
just have, you know, little little contests for the kids.
19:04
You want to have, you know, eight, nine, 10 different
19:07
strategies. We have offices right now giving out the new
19:11
Apple virtual reality glasses. Now they're $3,500. So you don't
19:15
buy 10 of them. What you do if you buy one, and you make it a
19:19
six month contest, where people can enter the win, and then it's
19:23
$3,500 over six months. So for some practices, that's a great
19:27
idea. Third, was referrals from existing adult patients. Now
19:30
that's going up regularly. You know, in the past, adults were
19:34
not the big referral sources, because we didn't have aligners.
19:38
They didn't want to do bracket and wire. And honestly a lot of
19:42
orthodontists don't like treating adults because you
19:45
know, they've got an opinion they are not as easy as the
19:49
kids. They don't come in with their air pods and never have to
19:53
talk to you to talk to. So the adult, I've said for years the
19:57
adult market was the greatest unexplored frontier and I'm
20:00
predicting that this adult referrals are going to grow as a
20:04
percentage of practice referrals every single year from here on
20:08
for a long time. Third was social media. But it's not
20:11
growing. It's interesting. Social media is so hot, with
20:15
orthodontists. And I like it, and you should have it, don't
20:18
misunderstand me. But number one, it's hit or miss. I, we get
20:22
new clients who are doing well with social media and we get new
20:26
clients who are not doing well with social media from the same
20:30
social media companies that they work with. So nobody has, you
20:34
know, every social media company I talked to, because we get
20:38
called a lot would you recommend us to your clients, and they
20:42
always kind of come at it from because we're, we have this
20:45
secret way of doing things that gets results, everybody thinks
20:49
they have the secret sauce. And the truth is, there's no secret
20:53
sauce, or we would all know it because everybody be reading
20:57
about it or publishing it online, or Google would tell us
21:01
or whatever. But social media is important. But it's not growing
21:05
as a referral source. It's flat, which is fine. And it's a little
21:09
bit up from 22. It went from 12% and 21, to 9% and 22, back to
21:13
12%. So if you only look at last year, and the 22 and 23, you
21:17
might say it's up 3%. That's a true statement. But it's only
21:20
back to where it was in 21. And again, I spent a lot of time
21:24
looking at this data to try to understand it. And finally, the
21:28
thing that dropped off, interestingly, was community
21:31
activity. Yeah, right. Now, I have different theories. And I
21:35
don't know which ones right because I don't have any data
21:39
yet. Okay. orthodontists spending less on community
21:42
activities, because of the pandemic or ortho which is over
21:46
mostly, or orthodontists spending less because things are
21:49
more expensive. Or, or is it just less effective, and people
21:53
are relying on other sources for their referrals going forward? I
21:57
don't know yet. But I'm gonna be really interested. I made a note
22:01
next year, the first thing to look at is referrals from
22:05
community because if it's flat or down, then that's a new trend
22:09
that we're looking at. It could have just been an off year. I
22:13
don't know.
22:28
effort, we meet people that only focus on the patients, we meet
22:32
people that only focus on social media. And that's great until it
22:35
runs out. And usually, they don't realize it's running out
22:39
till about three years late. orthodontists have what I call a
22:42
three year mentality, we don't wake up and pop up with a sign
22:46
that says, Oh, I have a problem till about three years in, and
22:50
then and that, then it takes longer to reverse. So number
22:54
one, I would diversify between referring doctors, patients and
22:59
parents and include a subset of adult patients, the community
23:05
and social media. But I would not do it evenly 25% 25, 25, 25.
23:12
Based on this data, I would put more investment into referring
23:16
doctors, I would put the next most investment into patients,
23:20
the third investment into social media, and then the fourth
23:23
investment into community, I would stay with the community,
23:27
but I would back that down quite a bit based on what I see here.
23:30
Now, having said that, you have to monitor your referrals, you
23:34
got to understand referral marketing, you need a minimum
23:37
quantity. The big secret here is not just to have quality, you
23:41
know, a good social media campaign of high quality doesn't
23:45
do it. You got to have quantity. How many times do you have to
23:48
touch referring doctors? How many times do you have to touch
23:52
parents, patients and adult patients? How many impressions
23:56
do you need with social media? You know, back in the old days,
24:00
when we only had print advertising, the you may
24:03
remember this, they said it took 17 times see an ad for the ad to
24:07
be effective. Well, social media, it could be 78. For all
24:11
we know, you'll we just don't know. So based on this, I would
24:15
definitely stay diversify, but I reallocate where I'm
24:18
emphasizing. And if I were a new orthodontist, I would go out of
24:22
my way to build my general dental referrals, even if
24:26
they're doing ortho, most of them are definitely not doing
24:28
all the ortho by any means.
24:31
Alison Werner: Yeah, right. Okay. Okay. So now let's switch
24:35
to challenges and we've touched on a few of these already, but
24:39
we asked orthodontists to identify their top challenges
24:42
for 2023.
24:43
Dr Roger Levin: Here you go.
24:46
Alison Werner: Yeah,
24:47
Dr Roger Levin: This comment first. I am a huge believer in
24:51
the economic law of supply and demand and in almost every
24:55
survey I'm ever involved in and we're involved in others and the
24:59
rest of it industry. We do surveys for William Blair, the
25:02
largest Wall Street analysis firm to analyze public
25:07
companies. So they want all the data, they engage us for
25:10
proprietary surveys. I always start before I interpret by
25:14
asking, does the law of supply and demand apply here? So what
25:19
does that mean? For many years and back when I was in practice,
25:22
as a general dentist, everybody did well. And we all thought we
25:26
were brilliant and good at it and great practice builders. But
25:30
to a large degree, we were fortunate that the supply of
25:34
dentists and orthodontists was low, relative to the demand for
25:39
services. So it's not a matter of being lucky. But the fact is,
25:43
we always we all look brilliant, when the supply is low, and the
25:47
demand is high. Well, that's shifting now. And it's shift,
25:50
it's past the neutral point, it's starting to shift where,
25:55
and I've talked about this with you before 25% of practices are
25:58
going to have better careers than ever in history. And the
26:03
next 25 are going to have good careers. The next 25 are going
26:07
to have much tougher careers and the bottom 25 may not even make
26:11
it they may end up selling and working for someone else. We are
26:14
seeing that fragmentation. So we have challenges today. And the
26:19
biggest challenge is not enough patient starts. Well, sure
26:22
because if I have enough patient starts, then nothing else
26:26
matters. I've got I've said forever, the only two things
26:29
that really mattered and building a world class ortho
26:31
practice, are the number of referrals and the number of
26:34
starts, everything else is just operations. Yeah, every
26:37
orthodontist can do most of the cases really well. You have to
26:41
have patients. So yes, patient starts was right. And these are
26:44
not my rankings. These are ranked, we have eight, I'm gonna
26:47
read all eight. We have eight challenges that were ranked by
26:51
the orthodontist in our study, and this is what they reported.
26:56
Yeah, so challenge number one, not enough patient starts. Well,
27:00
what that really means is not enough new patients. And it
27:04
wasn't reflected heavily in the data, but they may be feeling
27:07
something. And I've always said when orthodontists feel
27:10
something's wrong, they're usually right. People will call
27:14
me and say, I just feel like we're slowing down and their
27:17
practice is still stable. But when you feel it, you're just
27:20
ahead of the curve. In most cases, you're right. So if
27:23
you're feeling something, you're probably right. So number one,
27:26
not enough new patients starts that was reported by 71% of the
27:31
respondents. Number two, rising overhead, well, that's a vestige
27:36
of 2022. If we stay stable from here on, then a couple years,
27:42
the fact that it's higher than in 2022, everybody will forget
27:45
that and just say, Yeah, we're
27:47
Alison Werner: Kind of flatline.
27:48
Dr Roger Levin: Flatline, that's, that's a great word. And
27:48
Yeah, that's a good point. And so maybe that's something we
27:51
you don't want to do that. And Alison you summed up the whole
27:55
thing beautifully, better than I could. Number three, ability to
28:00
and it's interesting ability to retain and hire clinical staff.
28:04
Now, why is that so interesting? Because in the general practice
28:09
survey we do separately from this, it's published in a
28:13
general practice publication, this was number one, staffing
28:17
was number 1 in 2020, number one in 2021. Number two in 2022.
28:22
Overhead took the number one spot, but back in 23, back to
28:23
have to look at in the future surveys is that,
28:26
staffing being number one. So I was kind of surprised to see
28:31
this as third, but 48% said they staffing is a huge challenge.
28:35
But we also know that 64% of orthodontic practices are
28:39
currently looking for one or more team members to add either
28:43
as replacement or additive. Number four competitive threat
28:48
for GPS, 38% said that, that is more subjective. I my theory I
28:52
could be wrong. My theory is they're more focused on it
28:56
because they're annoyed about it. They don't like GPS doing
29:01
ortho. It means they're not referring to the orthodontist.
29:05
They don't feel the GPS necessarily have the skill set,
29:09
which is kind of true in that a lot of GPS do aligners because
29:13
the AI is in the trays artificial intelligence. But not
29:17
because the GPS like me have any additional ortho training. So I
29:22
think there's a bias there. But either way, as I've said to many
29:27
orthodontists get over it and deal with it because it isn't
29:31
going away. Number six, declining insurance
29:34
reimbursements, always a challenge. Seven, competitive
29:38
threat from DSOs. That one's going to move up that one's
29:42
going to get bigger, because DSOs like ortho and they're just
29:43
Well, there's a company out there, I know, we're gonna get
29:47
starting to add more and more of it. And some of the big GP DSOs
29:52
are starting to add specialists as well. And number eight,
29:56
competitive threat from direct to consumer. Well interesting,
30:00
that that was number 8 all the way down at a lowly 6% because
30:05
it's basically gone. Will it come back? Who knows? Yes, not
30:09
here now, I would worry more about AI and aligners allowing
30:13
GPS to be, you know, just distributors for aligners to
30:17
their patients. That's a reality that I talked about in my lectures.
30:31
to this, so I want to do it now. But they've got like, 126 data
30:35
points now. Not not for aligners, but under, but for
30:39
monitoring. And I'm studying monitoring really deeply because
30:43
it's going to be a huge factor. And a lot of orthodontists are
30:47
still in the denial stage. And I'm not an orthodontist. I don't
30:50
tell people how to practice. I look at market forces. And in my
30:54
career, I've been very fortunate and looking at market forces and
30:59
saying, Okay, this is something that's going to explode with
31:01
growth once it hits the inflection point. But again, my
31:04
point was not that it's AI driven. AI is going to play a
31:08
bigger and bigger role in the whole world plus orthodontics.
31:14
Alison Werner: Yeah, absolutely. Absolutely. Well, one of the
31:16
things you break out in the article is you do go a little
31:20
more in depth on dealing with the staffing challenges, which,
31:23
you know, in this year survey did start it came in at number
31:26
three. So you identified three, sorry, four opportunities, or
31:35
no, actually, I've got four for the top answers for Yep. Okay.
31:39
Dr Roger Levin: So, here's what's really important.
31:44
Staffing is not a shortage, it is a crisis. And even if your
31:49
production is not dropping because of it, which does
31:52
happen, the rest of your staff is exhausted. So if we had six
31:55
or 12 hours, I can talk about staffing from every dimension
31:59
plus burnout. I've read four textbooks now on burnout, just
32:04
to understand the difference between fatigue, frustration and
32:08
burnout. And again, that's not for today. My main message is
32:13
you want to focus on staff longevity, you want to measure
32:16
that every year. And I can give you many, many, many things to
32:19
do. But let's go through the four. What four things did
32:23
orthodontists say. This isn't, today's podcast is not about
32:26
what Roger thinks. If, if you think Alison, it's very
32:30
important if I think it today it's not. It's it's about what
32:34
did our respondents say. And they came up with four key
32:38
things that they're doing to try to retain their staff. Number
32:42
one, increasing base compensation. Okay, that's a no
32:45
brainer, because you're not people aren't gonna take jobs if
32:48
you don't pay them enough. And everybody knows, with full
32:51
transparency, what everybody's making. And if any of you have
32:54
an illusion, that your staff is not sharing their compensation
32:59
every day at lunch, then you are living in the Dark Ages. They
33:04
they know exactly what everyone's making. There's,
33:07
there are new laws. Now in many states where you have to publish
33:11
the compensation in your ad by law, and it's going to go
33:15
national, it's going to be everywhere. Yeah. Remember, it
33:18
is a labor market, everything happening is in favor of labor.
33:22
And I don't take sides I have to deal with what's happening. A
33:26
lot is gonna be a lot of regulations going toward labor.
33:30
For, here's an example, we have a client in California, that had
33:35
to pay a fortune to a 20 year employee who quit because they
33:39
never gave her 10 minute breaks on the regulation cycle and she
33:44
came back and sued and a lot of money. It was not small money
33:48
there. There are laws on when you get breaks how long lunch
33:51
has to be in different states, every state is different. But
33:54
pay attention. Yes, the number one increasing space
33:57
compensation. Number two, providing more bonuses and
34:01
bonus, the word bonus, you have to be careful, has a lot of
34:05
different meanings. I've written a book on bonuses. And it's it's
34:10
one type of bonus. But there are many there bonuses on
34:12
compensation, their bonuses on number of conversions, there are
34:17
bonuses on completing cases on time, and overdue debonds, there
34:21
are bonuses on collections. You tailor the bonus to what you
34:25
need to focus on in your practice. Right now, if you put
34:29
if you put a gun to my head and say, Well, what is the best
34:32
bonus? Now that I've said, well, there isn't just one, it would
34:36
be a production based bonus for the team where everybody shares
34:40
equally over a certain amount. So a bonus is not a giveaway,
34:44
and the Christmas bonus is not a bonus. Nobody cares. Nobody
34:47
thanks you. It's the 27th paycheck. If you're if you give
34:51
Christmas bonuses, it's just expected. Number three adding
34:56
technology for productivity enhancement. This is going to be
34:59
big and technology. It's early. It's very early despite all the
35:03
workflow technology, I am now studying workflow technology,
35:09
and how it can increase production and efficiency and
35:12
even replace certain labor and certain functions. And the
35:16
reality is that technology is going to be essential. Simplest
35:21
example, you walk into a McDonald's, there are no
35:24
cashiers, you order at a kiosk, and then you pick up your order.
35:28
Why? Why is that happening? Well, originally, it started to
35:32
save money in the testing phase. But now because they can't get
35:35
people to work there, and higher minimum wage is getting very
35:39
painful. And finally, number four, offering more and better
35:43
employee benefits, there are people to health care is a
35:46
fortune. There are people that want health care, they want to a
35:49
lot of orthodontists do not give dental benefits, which is kind
35:53
of ironic.
35:54
Alison Werner: Yeah, I've heard that. I've heard that.
35:58
Dr Roger Levin: You know, general dentists can give it
35:59
because they can do most of that stuff. You know, it's there's a
36:03
cavity or whatever. But a lot of orthodontists don't get dental
36:07
benefits. Vacation time is going to become more important. You
36:11
can't give this benefit, but working from home is a benefit
36:14
that a lot of employers are giving in the business world or
36:16
working from home part time, or paying part of a gas allowance
36:20
or things like that. So there are a lot of different benefits
36:23
and you need to tune into what matters to your orthodontic
36:27
team, because that's how you keep them. What matters to your
36:30
team is very important. So those are four items that are being
36:34
reported by our respondents. I agree with all of them. If as a
36:39
as the CEO of a consulting firm, these are all great ideas.
36:45
Alison Werner: Okay, all right. It's good to know that they're
36:46
on track there. Okay, so let's talk about starts and
36:50
orthodontic fees. So the average number of total starts per
36:54
orthodontists for, let's say bracket and wires we reported
36:59
204 is the average number of starts per orthodontist; average
37:03
fee for complete treatment for brackets and wires was 6,287.
37:08
And then clear aligners, we had 83 average annual starts per
37:12
orthodontist and an average fee for complete treatment $6,467.
37:18
Dr Roger Levin: Well, first thing is what's happening with
37:20
aligners. Again, anything I do an ortho, what's the aligner
37:24
effect, I call it I look at that intensely. It was fairly flat
37:28
and growth last year in orthodontic practices. There is
37:31
going to be an explosion; I'm still predicting five years from
37:34
now, it might be as high as 70%. Everything's getting better the
37:39
AI is getting better. The biggest companies done 22
37:42
million plus cases if I'm in the ballpark anyway. We know so much
37:48
more. We can do it for teens, we can do it for younger kids, now.
37:52
It's, again, market forces, it started with adults. Then
37:56
aligners went to teens, and it went to younger and eventually
37:59
we'll be doing them in utero. So probably the next few years, but
38:06
the point. So it's very interesting aligners have not
38:09
grown as much in ortho. Obviously, they're 95% plus in
38:14
general dentistry, because that's all they can do. But
38:17
having said that, I think aligners in the next few years
38:21
I'll be shocked if these numbers don't explode, as because
38:24
they're more and more parents and patients that are just not
38:26
going to tolerate anything else. They want aligners, and there'll
38:29
be practices that are more than happy to do that for them, if
38:32
your practice doesn't. What's really interesting are the fees.
38:36
You know, we first started with aligners, partly because of that
38:39
$1,800 lab fee that was out there, everybody put a much
38:44
higher aligner fee than a bracket wire fee. They also
38:47
didn't have the competition was between orthodontic practices,
38:51
not all these other service delivery models. Well, now that
38:54
that's changed, I'm not surprised that the bracket and
38:57
wire fee and the aligner fee are pretty close to within a couple
39:01
$100 of each other. And that's the big takeaway: Watch your
39:05
fees because you are competing. You could you don't have to have
39:09
the highest fees, you have to have higher volume, which means
39:12
more systems, better staff training, more scripting, better
39:15
run practice, more efficiency. You can be very profitable that
39:19
way, but if you raise your fees too high, you're gonna lose a
39:22
lot of cases and the tolerance, where I still predict we're
39:25
gonna see orthodontic practices with two tiered fees where the
39:30
sixty 62 and 6,400 is the high end. Listen, I know there
39:34
$10,000 cases out there, and maybe half of that might be the
39:38
lower end and I think we're gonna see both. Again, market
39:42
forces otherwise, what practices will start doing it when they
39:45
don't have enough starts. We're not there yet. I hope we never
39:48
get there. But unfortunately, I think we're going to get there.
39:51
Alison Werner: Yeah. Okay, so now let's look at the changes in
39:58
patient visit intervals. So the time in between checks. So for
40:02
let's see, treatment for bracket and wire for in person visits
40:06
we've got seven weeks is the average time between visits; for
40:10
for remote monitoring visits for bracket and wire, we've got
40:12
eight weeks, and then clear aligners, we've got 10.1 weeks
40:15
for in person visits and 14.7 for remote monitoring visits. So
40:19
what's the takeaway here?
40:21
Dr Roger Levin: Well, there's several takeaways. First of all,
40:24
it's up a little bit. And you know, bracket and wire, seven
40:29
weeks, remote monitoring, eight weeks, I want to tell everyone,
40:32
before I make any more comments, I'm not speaking clinically. We
40:35
have never told an orthodontist how to practice. That's not what
40:38
we do. But we can tell them what's happening out there. And
40:42
it's very interesting with aligners, 10.1 weeks, and remote
40:46
monitoring, 14.7. So let me tie some thoughts together, remote
40:50
monitoring is going to grow very, very quickly. It will
40:55
become part of every ortho practice in the country, or 90%
41:00
of them, and in within five years. It's just there. Now,
41:04
anybody listening that doesn't like remote monitoring—and
41:06
that's a lot of you, I understand that today. But
41:09
remember, we didn't like aligners when they first came
41:12
out either way, if we don't like a lot of things when they first
41:15
happened. Yeah, I'm gonna predict that this is going to be
41:18
huge. The market forces are there. I'm studying it, it's
41:21
getting, it's getting better monthly. A lot of practices have
41:25
no idea how to manage it. They don't know how to put in place a
41:28
remote monitoring staff member; they don't know how to make it
41:31
work. But it's going to come. And we're, it's so important.
41:35
We're starting to incorporate how to manage it into our
41:37
consulting because we're there; but you know, again, I don't I
41:40
don't want to be behind for people. And if somebody doesn't
41:43
need it fine. But we're putting in our program how to deal with
41:46
it, because we're there. So, but here's, here's what I'm going to
41:50
say and this is my opinion. Now. It's a mistake. These intervals
41:54
are way too short. I think we're going to find I have clients
41:59
very fine orthodontists very dedicated, very smart, where
42:04
it's with aligners, it's 18 weeks between intervals, but
42:09
with remote monitoring, it's 24 to 28 weeks, we even have
42:12
somebody at 32 weeks, and as far as I know they're highly
42:16
dedicated. They're not we know they're not getting negative
42:19
feedback because we survey patients in our program. And
42:22
again, ultimately, they want a beautiful smile. I always
42:25
explain to orthodontists and TCS, forget everything else,
42:29
gear everything toward one thing, the beautiful smile. But
42:33
these intervals are going to grow. And I encourage
42:37
orthodontists take a hard look at making them longer. You don't
42:40
you know, I'm not telling you had a practice, if you don't
42:43
believe in it, that's fine. But otherwise, you're only at this
42:46
cycle because of basic habits and your comfort zone. But with
42:51
remote monitoring, everything's going to change. We have a
42:55
company in Europe, also for dental, dental and ortho
42:58
consulting, and in Europe, there are orthodontists that see the
43:02
patient for the start and everything else is remote
43:05
monitoring. Now, I'm not promoting that. That's not my
43:08
role. I'm not a clinician, but Europe's way ahead of us in
43:12
terms of the intervals, and they're comfortable with it. Now
43:15
somebody might say, well, they're not as high quality as
43:17
we are. I'm gonna challenge that we won't know for a little
43:21
while, but I think they're just more open to this particular
43:25
methodology of interval setting.
43:29
Alison Werner: Okay, well, you we also ask the question of how
43:32
what type of appointments doctors are conducting remotely.
43:36
So the number one type of appointment was the orthodontic
43:40
check. Then we did new patient consults, retainer checks,
43:43
emergencies and then new patient exam. What kind of was your
43:47
takeaway from that?
43:48
Dr Roger Levin: Oh, it makes perfect sense. I think
43:49
orthodontists often view the check as of minor importance.
43:55
Now if you've got to change a wire or something, that's fine.
43:58
But the orthodontic check is just that it's a check. And
44:01
it's, that's an orthodontist do most of the afternoon. Check,
44:04
check check. Frankly, a lot of staff members can do it pretty
44:07
well. So 72% are using some type of monitoring or teledentistry
44:14
for checks and ortho is the only part of dentistry really using
44:18
teledentistry, it's under 3% in general practice. It's not going
44:21
anywhere. You know, during the pandemic, everybody was
44:24
predicting where it was going to go and wanted to invest in the
44:27
companies. And these aren't microchips. Now teledentistry is
44:30
going to have a very minor role in general practice, oral
44:34
surgery, endo, perio, pedo. But for ortho, it's fantastic. You
44:39
can save so much time. I love it for checks. I would do as many
44:43
checks as you can remotely. In terms of the new patient consult
44:48
Alison Werner: What about that?
44:48
Dr Roger Levin: Well, here's the thing, be careful. The
44:51
technology is fine. But we don't know what happens when you don't
44:56
have a live meeting and room consult and relationship. I am
45:00
very concerned about practices is trying to do their new
45:03
patient exams and consults remotely, I think that I don't
45:09
think that's going to be good. You need to get that parent and
45:11
patient in to select you. Third retainer checks. I have said for
45:17
30 years again, my opinion, do twp, and they and by the way,
45:21
they won't show up for the second one anyway. So 50% on
45:28
retainer checks don't come in on average. Think about that. 50%
45:32
though. So they're just a waste of time, they eat up chair time
45:35
you're never getting back. You're losing it permanently. So
45:39
I love it for retainer checks. I think I think remote monitoring
45:42
for retainers will be over 70% within five years easily.
45:47
Emergencies, fantastic. Because what you're really determining
45:51
is, do they need to come in? That's all and how quick. Yeah,
45:54
is it emergency? Yeah, stop blowing up your schedule and do
45:58
a remote exam. And finally, the new patient exam. Again, be
46:03
careful. Right now, I would advise clients get new patients
46:07
into your office so you can control the incredible new
46:11
patient experience. And they start with you. So but ortho
46:15
checks that's only going to rise and rise rise. That's the easy
46:18
one. And that's almost double the next closest remote
46:23
monitoring.
46:25
Alison Werner: Okay, so another issue that came out of the
46:30
survey findings was we found that almost one quarter, 22% of
46:34
orthodontic practices do not have a full time treatment
46:37
coordinator. What's the takeaway from...
46:40
Dr Roger Levin: It's the first time we've asked that, and I was
46:43
shocked. I was absolutely shocked the way we asked it. If
46:48
you don't have a TC, get one. Number one, they will save the
46:53
orthodontist so much time you know, even though ortho goes
46:56
chair to chair to chair, you still have to look at it from a
46:59
doctor production standpoint. Every time a doctor is at a
47:02
chair that's production. Every time a doctor is at a consult
47:05
that's not production. So excuse me kind of sneeze there. So we
47:11
want orthodontists in the main clinical area with parents,
47:16
patients and adult patients as much as possible. We the
47:20
throughput, the volume we can put through is much bigger in
47:23
most ortho practices. Remember, let's cycle back to the
47:26
beginning. They're mostly running $500,000 a year,
47:30
production below potential. So you want to get a TC. Number
47:35
two, the TC is going to spend more time. These are hour
47:38
consults, you build relationships, you learn about
47:41
the parent, the patient, you learn why they're there, you
47:44
build commonality. And what we teach, and we teach it minute by
47:49
minute, step by step, build a relationship. It's not just a
47:53
sales job, it is building a relationship to build trust to
47:57
get a start. That's what you really want. You want mom going
48:00
home and 80% of the time it's mom saying to her husband, we
48:05
this is where we need to go, this is the right place, we're
48:08
not going to another place for $400 less, because the husband
48:12
wasn't there. It's typically the husband, when mom comes home and
48:15
says oh, we went to the orthodontist today this is get
48:17
another opinion. So you know, because even in our equal world,
48:23
husbands do a lot more of the daily checking account, they're
48:26
watching some of the money and and men are often more likely to
48:30
bid it out. Especially if they didn't hear the presentation. So
48:35
you need a TC that's trained exactly what to do. And the TC's
48:40
today are not the TCs of even five years ago. They need to
48:44
understand there's competition out there you need to be
48:48
building your scripting to incorporate why come here before
48:53
anybody asks you or doesn't bother to ask you. So the TC
48:57
today has to build value, not just explain orthodontics, you
49:01
can't take a former assistant and stick them in that role with
49:05
no training and expect them to do well. This is a professional
49:09
sales position to build relationships engender trust,
49:14
and create starts and then measure them and measure them
49:17
and measure them.
49:18
Alison Werner: Okay, so what's your overall message to our
49:26
listeners and our readers?
49:27
Dr Roger Levin: Well, I started by saying the word from this
49:30
survey is stability. And that's a good thing stable is good, but
49:34
stable doesn't stay stable. And when I look at the trends
49:39
between an economy where some basic goods and staples are
49:43
costing more money, and that's what people look at, in an in a
49:49
competitive landscape where we have DSOs and general dentists
49:54
doing more with aligners. We have ortho only DSOs but we've
49:58
got the big boys and orals as I call them starting to bring in
50:02
more ortho because it's lucrative. We've got staffing
50:06
challenges, and which even we put aside the frustration, and
50:11
headaches, we've got higher overhead that needs to be offset
50:15
by higher production. So my message is, if there was ever a
50:19
time to organize your practice, streamline it was systems, get
50:25
everything in place as if you were declining, even if you're
50:29
not, this is that time, because right now we're stable. So
50:33
you've got time to get it right. But if we happen to go into some
50:38
decline, as I think a lot of practices will in the next few
50:42
years, not, I'm not gloom and doom, not tomorrow. But the best
50:46
time to build is before you have a problem. And it's also easier
50:49
and faster. But I'll end where I started. Any practice can do
50:53
well, if it applies the right methodologies and systems and
50:57
practice management. But you can't just rely on that economic
51:00
law of supply and demand anymore. It's not as much in our
51:04
favor as it used to be.
51:06
Alison Werner: Yeah, absolutely. Well, Dr. Levin, thank you so
51:09
much for taking the time to break this all down for our
51:12
readers and
51:13
Dr Roger Levin: our listeners. Thank you, Alison, is always a
51:15
pleasure to be with you.
51:17
Alison Werner: Great well, and to those of you who want to
51:19
learn more about the survey, it will be in our upcoming
51:22
April/May issue, which will if you don't get it in the mail,
51:26
then you can also find it at the AAO at our booth. And you can
51:30
also find the article online and we'll have a link to the full
51:34
article with this podcast. If you go visit our website. So
51:37
thank you for joining us. And thank you again, Dr. Levin. As
51:40
always, thank you for joining us. Be sure to subscribe to the
51:43
Orthodontic Products podcast to keep up with the latest
51:45
episodes. And be sure to check out orthodontic products online
51:48
dot com to keep up with the latest industry news. Until next
51:50
time, take care.