Thriving within a PPO Practice!

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Welcome everybody, to a new episode of the Dental Boardroom podcast here at Practice cfo. We are a dental CP and financial advisory firm working with dentists throughout the country. And we want to create great content to share that is relevant and useful for dental practice owners as CEOs of their business. That's why we have recently rebranded the podcast to be called the Dental Boardroom with the concept of a boardroom having some of the key executive leaders in a company. And even though a dental practice is a small business, you have a CEO who is the dentist, the practice owner. We like to play the role here at Practice CFO of the CFO or chief financial officer of your practice to help give financial guidance. I'm excited today because we have a returning guest on the show, Dr. Bob Marcus. Welcome back to the podcast, Bob.

Thank you, Wes. It's good to be back.

It was a couple of years ago that you were on the program and you sold your practice about four years ago. We helped you sell, and that's when Bob and I got to know each other. And I have stayed in touch with Bob over that time. He is now doing practice management consulting. He. He sold. He sold his practice at 51, healthy and strong, except for one thing, and.

That was my eyesight.

Eyesight.

See, I had some problems in my eyesight and doctors and treatments and MRIs and lots of stuff that I never thought would happen to me happened to me. And I had to pretty much up and sell the practice. One day I was prepping crowns and two weeks later I was selling to practice. It was kind of sudden and sad and emotional, but here we are and four years later and all's well.

But I think you did that process right. And Bob and I just got done doing a podcast on my other podcast series called A Practice Orbit. The Practice Orbit podcast series, which is a tech side of my professional life. And he. And we talked all about that selling experience. So if you're interested in what that was like, if you're thinking about selling, staging your practice, what's the process like, maybe even some pitfalls. Just a really good podcast there. Head on over to the Practice Orbit podcast. It's actually our first one over there, so pretty easy to find. Today, though, we're going to talk about something different. We're going to talk about what Bob is doing now as a consultant to dental practices. We've had you, Bob, in a number of our practices at this point, and without fail, we see very, very positive outcomes.

We've done well. I've been really Pleased with what we've been able to help out.

One of the things that you've been able to help doctors solve is an issue of a inadequate collection level, an inadequate adequate. We use the term top line, which is simply how much revenue or how much collections do you have? How much money's hitting your bank account from doing dentistry, we call that top line. And then you have, as Bob states that, all these negatives, all these expenses. You got labor, supplies, lab facility, marketing, admin, Golly's expenses. And then you get to your bottom line, and that's your profit. And that profit is then used to pay yourself, to pay your taxes, ideally fund 401k and maybe kids, education funding, all those things that you want to sort of do and accomplish in your life that have a price tag to them. But Bob's focus is primarily top line. How do we grow your practice collections? Because if we can solve that problem, most of the other problems work themselves out. And most of the other problems are small relative to the problem of an inadequate top line. Did I state that correctly, Bob?

Yeah, it's pretty close. I mean, most doctors know, if you ask them what are the important numbers in your, in your business, they'll say, well, I know my production, my collection, and how many new patients I had. That's pretty much what we know as CEOs. And that's what I always knew. And then over time, even though I didn't get this in dental school, where I went to school, nobody talked about stuff like this. I actually got pretty good at the other aspects of being the CEO. I don't know how maybe my. I don't know how. Maybe my father was good at it. He owned a tiny little antique shop in Connecticut when I was a kid. And maybe, maybe I just inherited it. I don't know. But I got good at the other aspects of it. And I'm not talking about finding ways to save $0.03 on every carpool composite. That's not it. I got good at helping that top line grow. That that was my goal. You know, we say collections of production. In my world, those are the same thing. They should be equal to each other. If they're not, we have a different problem that we need to solve. We say new patients. Well, yes and no. If we've been established dental practice for a while, we should be having plenty of new patients without advertising. And if we don't, then we have that problem to solve. So my job is to kind of go in and just fly my helicopter well above the office and look down and go. Okay. I want to judge everything from how does the front door look on the way in? To what was the entire experience of the patient while they were there until how did it look on the way out? And if that little. I always call it the lazy river. It's one of the buzzwords I use. If you go to one of these hotels, they have one. They have these lazy rivers. You ever heard of that? Where you lay in the raft and you float around.

Yeah.

And you don't really have to do much to go around and round. But if you are on that lazy river and you drop your sunglasses or you get to the steps and you just went by them and you want to get out and you got to go backwards, that's not that easy. You then realize just how powerful the current is, and you're fighting and fighting and fighting your way backwards. And Dennis, do it all the time. I want the patients to feel like they're on the lazy river. I don't want turbulence in the. In the moment that we have. We only get, what, an hour with them every six months or whatever it is. I want that to be so well crafted that they come back, they spend money when we tell them they need to spend money, et cetera. So that. That's kind of what I got to doing now. I'm doing it by mistake. I'm only doing it because, you know, because I had to retire kind of involuntarily. Suddenly. I felt like I wasn't done yet. I kind of had this I need to do something with my life kind of thing going on. So I went into the consulting field, initially working with a company called Accelerate My Practice, and then later on my own. And the idea for me is to kind of apply something that I can give to dentistry that I can still do without being able to see it all that well. So I'm doing everything in a dental office at the CEO, or I'm teaching the CEO how to be a real CEO, except for the drilling part. I can't really teach that anymore. And they kind of have to be good at that on their own. So I don't know if that explains it. It's kind of a long explanation of saying I just kind of go in and figure out the systems.

Well, whatever you're doing is working. I think that's a great explanation of it. We're going to focus on one aspect of this.

Yes.

I thought there was a subject that was not controversial. I thought it was universally accepted that PPOs are the enemy of all Things good in dentistry. That's. We have a number of podcasts on the value of going to fee for service. I've talked about how many PPO Delta crowns if you're on sort of the new Delta PPO fee schedule, how many Delta PPO crowns you have to do to equal the profit of one fee for service crown. I've gone into this quite a bit and some of my colleagues have as well. You and I were talking the other day and you said, Wes, PPOs are not evil. There's a way to work the PPO system to have a very successful practice. That is the subject of today's conversation. Are we all good with that, Bob?

We are, Kat.

Let's. Let me just. I'm gonna just jump in as this whole devil's advocate thing here and then have you kind of defend. Not defend the ppo, but I want you to make your case.

I wanna make it clear. I don't love PPOs. I don't have a thing for them. I just realized that in some cases, it's a necessary evil for certain practices. So if we have decided, hey, I need to be a member of this PPO because I'm not willing to go out of the network because of the demographics of my practice, because I'm too fearful to get out, whatever the reason, you have to. To stay in while you're in that network and while you have voluntarily signed that contract. How can we make that work for us instead of against us?

Okay, got it. So then you're already addressing what is my concern, slash initial doubt about the effectiveness of working within the PPO model. Now all I have to do is really look at your practice. We helped you sell your practice four years ago, 2019. And I got your financial statements. I wasn't your CFO at the time. And that's okay. I've forgiven you of that. And I brought that up like 10 times to you.

I still love you, Wes.

That's. That, you know, it's. I admire loyalty. And you've had. Hey, I've always said if you come to me and you got it figured out, your CPA is engaged, doing a great job for you, and you've got a financial advisor who cares and isn't just there to sell you a product, and they're. They're leading you to the promised land of financial freedom, great, I don't hire me. Don't hire me.

And I. I absolutely would hire you. We've had the same guy for 27 years, and they've been fantastic for us. So that I guess the loyalty thing keeps me there.

And I'm also, I was also relatively newer here. I'd started here in San Diego 2014 or 15 and was only starting to make a name for myself. I think around.

I've been here since the late 90s.

Yep, yep. It would have been an honor. But my point is, is that when I got your financial statements, when we went to help you sell your practice, I saw immediately, here is a top 1% practice. With the, A lot. With the amount of collections and the profit margin being so healthy, I thought this is a fee for service practice. We'll come to find out it wasn't. What percentage of your collections were from PPOs.

Okay, so you said a couple things that I'm going to eventually take issue with, but I'm going to answer your question first.

Okay. I like our relationship, Bob.

About, I'd say about 60% of our patients were in network PPO. We did have some PPOs that were out of network and that accounted for maybe another.

10, 20%. And then the rest were just, you know, self pay. What I call self insured patients, I don't call them cash. I think such a weird word.

Kind of the true definition that we all think of. That's a fee for service.

Yeah. And I think a fee for service, I get that. But maybe I'm just looking at the words because I'm kind of a literal personality. And when I look at fee, that's the money comes in and then services, I did something to earn it. So even though a PPO pays me less for that crown than my regular, you know, self insured or cash or ucr, whatever you want to call it, I still am fee per service. It's just that fee is a little lower. And that's, that's, I mean, let's be very honest, the difference between being in versus out of network or whatever is you just have some rules you have to play by. And the biggest one, the one that affects us most is they control how much we're allowed to charge for the procedure. They control that this is it. You could. What's your rate? You know, my regular crown fee back then was probably, I don't know, maybe $1,600 for a crown. And the PPO was probably 900.

Now was that a Delta Premier?

No, we were a Delta PPO provider.

You were okay. I'm surprised you didn't have grandfathered in the Delta premiere getting the higher rates. And I think PPO these days is a, is less than 900, I could be wrong.

It might be 800 and something. Although, you know, we, we, we, we have little things you also do. But the, yeah, I don't know the exact numbers and Premier is kind of going bye bye.

Yeah, it mostly is.

And people if you're either in the. And I think if you join up now, you join up both automatically. And I think that it's a teensy bit of the patients that are Premier. Everybody's just PPO a Delta. I think they realized their mistake there because every year people would send their fees in and everybody had their own fee schedule and it was a mess. And so I think they just said hey, this, this was dumb, let's just put everybody on the ppo.

So you ran a successful practice by all things, as I, as I define success financially speaking in the practice. And, and now you're out helping a lot of doctors and a lot of these doctors have this sort of romantic notion of going quote, fee for service or really going cash basis ucr, UCR based payment and out of network from the insurances and not so dependent therefore on the insurances to get people in the chair. And there's a whole process around that and branding and experience and training with your team and language and scripting, all that stuff for sure. But you really introduced to me the belief recently that you can still thrive with ACE with a largely a PPO practice.

And let's be very, you know, when I look at doctors, everybody says, oh my God, I can't believe Delta. I can't believe MetLife did this to me and ruined my life. So in my location, which is Poway, California, within about five miles of my office, I have Northrop Grumman, General Atomics, Hewlett Packard, Apple, a huge school system and many others that carry PPO insurance. This is my patient hole and you. We have to be honest with ourselves. I think a lot of us have a hard time just looking in the mirror and being honest with ourselves. There are a lot of doctors say I hate Delta. Delta ruined my life. If I went around the room and said let's do a stream of consciousness. I say a word, you say one back, red, blue. If I said insurance or they'd be like, oh my God, sucks horrible, ruin my life. And what happens in the end is people have this negative view toward insurance. I don't have a negative or positive view toward insurance. I have neither one of those. I just have a mathematical view toward insurance. These are just facts of life for the crown. I'm going to do for that person, I'm going to make X dollars. How do I be efficient in that process? And how do I embrace the fact that, that this patient. Let's think about the patient for a minute, Wes, because all of us, when we walk out of dental school, we say the same thing. Why'd you become a dentist? If your friend said you, why'd you become a dentist? You would say, I want to help people have better dental health. Now are we just paying lip service to that idea or do we really honestly mean that a lot of we don't come out of dental school? I want to be a dentist because I want to make a crapload of money. If that's your attitude, well, then you're, you're, I don't agree with that. I just don't see that as you thriving in the health care world. If my true attitude is I want to help people have better dental health. If somebody comes in and they carry a PPO card and I'm going to go over the specifics of this, let's just say generally speaking, they waive their PPO credit card or PPO card, I'm on Delta and nobody has a card these days. They have a number. I'm on Delta. Guess what? That nice person who's my patient, who I have a nice relationship, can have his or her dental work done with a lower out of pocket expense. Okay? I should be celebrating that fact that I have assisted in a way for that person to get what care that person needed with and reduce his or her own expenses so he or she can use harder their hard earned money to take it home and put it in their 529 fund or go on a vacation. So to me, trying to work around the system and see, you know, what kind of tricks can I use here? What kind of insidious, you know, under, let's say undercurrent style tricks can I use to make my patient pay me more? I don't, I don't really go for the ethics of that. Here's the thing. When I became a member or a network provider, let's call it, of Delta and we're, we're beating on Delta here, but they're the biggest, especially here in California. I signed a contract with them and it's a long and I put my name on that contract. If I sign that contract and literally turn around and say, well, this sucks, they ruined my life. They're, they're taking my money, I have a negative attitude toward that. I should have never signed that contract. I voluntarily did It. So for dentists that want to have that attitude, just get out of the contract. It's that simple. Now, wait a minute, people listening to this podcast to go, oh, yeah, sure, that makes a lot of sense. I'll just go out of the contract and let my practice go bankrupt. So wait a minute. You're telling me that the very contract that you voluntarily signed and you are now financially somewhat dependent upon it to keep you out of bankruptcy is the one you're going to moan and groan about all day? I just don't see how that works. I don't see how that reconciles that we're. That, that we're. We're. We become these people that complain and we, we want to bite off the very hand that feeds us. I just don't agree with that. I think working within the framework and we can talk about specifics in a minute, but I think generally speaking, it's an attitude thing. If I voluntarily wanted. When I bought my home, I signed about, I don't know, 50 different papers to buy a house. I didn't sign my. On my. For my house voluntarily and get a mortgage voluntarily, then every time the bill comes, swear at the bank, okay, this was my decision. If I don't want to have that anymore, I can sell it and get a cheaper place. I just don't understand how we go into these relationships, let's call it. You have a relationship with Delta, like it or not. It may not be a good one, but it's a relationship. It's a, It's a, it's something we voluntarily went forth, and yet we, We. We just hate on it. Yeah. I just choose not to live my life that way. And I think that comes through to my patients.

Yeah. And to be fair, Delta is a business just like my business and just like your business. And there's owners, there's stakeholders, shareholders, there's employees, and they are trying to run their business as anybody would, which is we all want to have as much sort of influence and control and I'll even say dominance in our spaces as we can and profitability and sort of juggling it in the lifestyle that we're targeting. And so we can't blame them for that. Sometimes we look at what, maybe what the CEO is paid and we get. We throw our hands up and say that that's just not fair, you know, and then apply.

Then apply for that job.

Right.

I don't know how we badmin this guy, whoever the CEO is, and I don't even know who it is, and he probably makes a lot of millions.

It is the nature of our worked.

His way up through to economics and.

We should congratulate him for our capital system. And that's a whole different argument. As long as you support our capital system in some ways I get that you can't badmouth Delta for just doing what a company in our capitalistic system is going to want to do, just like Apple does and just like Tesla and a lot of these other companies that we're all sort of ooing and awing about is they're trying to do the same thing, which is to create a value, create something that people will sign a contract or, or sign a receipt for or whatever to buy that thing and get value in their life. So we set setting that aside and we say, okay, maybe Delta isn't the evil, I don't know, the evil force in the world. Dentistry, the evil stepsister.

Yeah, I don't even know what that means.

But exuding its wrath across dentistry. Let's just assume that's not the mountain, the intent of them. They're just in business. And so we're in business. How do we make it work? So if you step into a practice and let's say they are 60% PPO or 70% in network or whatever, let's get down to some of the specific now, because it is more difficult clearly to have a profit off of a PPO patient than it is a patient paying in cash. When you go from say 13 or $1400 for a crown or $1600 for a crown down to $700 for a crown with the same overhead, that really erodes into the profit which you need to pay your expenses and to pay your debt and to take home money and that student loan debt of 4 or 500,000 that's sitting on your books. Not you obviously, but younger dentists, you have to worry about that.

I had $185,000 in debt when I got a dental school in 1993, which.

Is like one year of.

But that's in 1993. In today's dollars. It's probably, it's probably double that. So I get that. I get it.

So what, what specifically can a dentist do to maximize the bottom line profit from a largely PPO driven either practice? If we look at it sort of at the macro level or the patient specifically, if we look at it at a micro level.

It's a good question. It's impossible to answer in a short podcast. We could do 20 podcasts on this. In fact, this is My space. This is what I do. And when I go to a doctor's office, and this is, by the way, this is not an advertisement for my service. I'm just letting you know we are literally full right now with a waiting list. I don't have an advertisement. My advertisement is the same as when I was a dentist, which is word of mouth.

And by the way, Bob does not have a team. Bob does the work, everything independently, exclusively, takes on four, four clients at a time. And so there's my half retirement job. There's a little bit of waiting list. So if you are interested in Bob.

Reach out to him, call west, get.

On the list at least.

No, but, you know, specifically, if you're a doctor that's listening to this podcast and you're saying, look, I have a lot of PPOs in my office. What do I do? And if you really think. And you just got. And again, it's one of these moments that we always talk about, of the looking in the mirror moment. Spend a moment with yourself, look in the mirror and say, where do I want to go from here? And if you come to the conclusion, as did I, that I have to have these PPOs in my life, I'm stuck with them because of the demographics of my practice location, because of the fact that they're so dominant here or whatever you decide, or because, like, I decided I want to serve this patient pool. I want to serve this patient pool. I have a lot of friends who have that literally carry that very insurance. So how do you make it work? It's actually rather simple. Number one, we need to figure out how to be efficient. We need to figure out how do we make our time more efficient. And this is something that I do when I evaluate. You don't need me. Just do it on your own. Map out a day. What did you do all day? I hear from doctors all the time, these exact words, Wes. Literally these words, I am so busy, but I'm not making enough money. Now, wait a minute. In most businesses, if you were so crazy busy, you would have so much money, you wouldn't know what to do with it. The goal of any business is to be busy, right? Agreed. So how do we become more efficient? So here's some things I added to my particular. My own personal office to be more efficient. First of all, leveraging. Leveraging to me means what can others do for me to earn money where I don't even have to walk in the room? Okay, so strong hygiene program here is a fact of life. And I could prove this to you. We're on a podcast right now, but were we directly meeting with one another? I can get out a piece of paper and show you what with your own office numbers, that in hygiene, if you're not doing having a strong periotherapy program, you're literally just throwing money in the garbage. Periodontal procedures pay better than normal cleanings. And yet I go to many offices where they don't probe more than once when they feel like it. It's not done every year. Patients are not talked to properly about their periodontal health. People slip by with, oh, just floss that area better. We're not using Arrestin.

We're.

We're not recommending fluorides, and we're not doing what we can do in the hygiene room to help improve the patient's life and also improve our bottom line simultaneously. Because if you can do both of those simultaneously, that's what a doctor's supposed to be. Okay? A dentist drills stuff. A doctor takes care of a human being. And if a human being can be better off having seen our office, and when they leave an hour later, they're a little bit better off than they were when they got there, then we've achieved the goal of being a doctor. So, hygiene. Leveraging that hygiene department. You'd be shocked at what I call opportunity in a hygiene department. In fact, I just looked at one of your own clients, and I will show you on my laptop later the opportunity just in that department alone. Leveraging. The only way you can leverage yourself as a dentist is what you could have a hygienist, an associate, which I don't believe in. Or you can have a. You could sell products. Yeah, I don't love products in a dental office. We're kind of up against Amazon these days and the Internet for price. So to me, hygiene is a very important place to leverage ourselves. Secondly, efficiency in your own steps. What are you doing? One of the things I incorporated into my office very strongly was cerec. CEREC is a very efficient way to fabricate crowns, inlays, onlays, veneers, implant restorations, etc. It works beautifully if you have if for people that have not used one of these in a while, if you take a look at the new systems, you almost don't need to do anything. I mean, the programming is ridiculous. You go in, imagine this. Imagine if your steps were as a dentist. Here's your entire crown procedure, start to finish. You walk in the room for a couple minutes and put some Novocaine in there, you walk out and you leave for a couple minutes, go do an exam or something. By the time you get back, the patient is numb. And two of the three scans, the pictures in the machine are done because your assistant did it. You prep the tooth normally, Dennis? I don't know. Listening to this podcast is probably some variation. I would say prepping a typical tooth would take me maybe 20 minutes. I prep the tooth, I press a few buttons on the machine to do the so called design, which takes about five minutes. The next thing I do is I leave. I have now invested about 25 or 30 minutes. The next time I go back in that room is about 40 minutes later when my crown is finished. It's been tried in, it's been looked at by the patient, it's been x rayed, the contacts have been checked, the occlusion has been checked and I cemented in, which is a process, takes five minutes. So my personal time for a crown is somewhere around 35 or 40 minutes. Now what am I doing during that 40 minutes while I'm in the other room doing another one? Sarek was so beneficial to my office, I bought a second machine. I find a CEREC machine pays for itself almost immediately. I think if you're doing, you know, 10, 15 crowns a month, which if you're not, we have a different conversation. We have to have then the efficiency of using cad, cam, especially Sarek, because SARIC is the most integrated. To me, SAK is like Apple. You know, everything's just integrated and works well together. There are other competitors out there that certainly aren't bad. I just think the SARIC is easiest, it's a little more expensive. It's just like Apple, but it's easiest. So to me, that's an efficiency. When I'm doing crowns, veneers, inlays, onlays, restorations for composites. We're always very efficient in what we do. If you in your office, Dennis, look at yourself in the mirror right now, it's a mirror moment. I always call it, look at yourself in the mirror and say, do I have a box somewhere of about 50 different tubes and bottles of stuff that we pull out when I'm going to do a filling. If you do, we need to become more efficient. Let's look at the actual materials we're using. Let's use efficient ones. I happen to purchase all my materials from a company called Ivaclar. Their lineup is very simplistic to use. It's the same exact bonding agent that I use on a filling that I'll use on a crown. We just have less bottles and tubes. So, again, I don't work for Ivaclar. I don't get a kickback from them or anything. I just use them. There are many companies out there that make this stuff. They're all out there. Become more efficient in your movements. Get your assistants trained. I have a lot of doctors. Oh, I don't let my assistant do that procedure. I don't let her. I don't let her adjust the contacts. Well, to me, that's either trust or training. Either you don't trust the person in which case you got a problem, or you haven't trained him or her well enough.

The second major thing. So after we get ourselves efficient, we get our hygiene department. We get ourselves efficient. We need to look at our front desk. What are we doing up there? If you're that doctor that says, I need more new patients, I need new patients and new patients. I need Google Adwords, I need Instagram, I need door hangers. Whatever your method of advertising is, something is wrong. I can't stress this enough. If you have patience, if you're so busy, remember we defined you're so busy but not making enough money. If you're not having those patients send enough patients that you literally have no time at all to put new patients in, something is wrong. Your patients should be your. Your marketing. Now, I would guess you would call that internal marketing, although I don't actually like that. That word, but I get it. So efficiency, delegating, internal marketing. We need to go to the front desk. We need to take a look at what they're doing. What's our recall system like?

I.

How often are our patients coming in? Are we fighting the patients? Are we fighting cancellations? Why? And then the other big nut is combining treatment. When you do a treatment plan, do you do a comprehensive treatment plan? Every doctor says yes, but do you really. Do you really do a full treatment plan on everybody? I was at an office once and a front desk person came to me and said, hey, I don't know what to do with this. I had a patient call. I had an. Excuse me, I had an orthodontist call and say they want the records for this couple that we just saw a couple weeks ago because they want to do Invisalign.

Right?

I talked to the doctor about that. You know why they didn't stay at the GP who does Invisalign and does a very nice job at it, I must say. Why didn't they ask us, the gp? Because we never mentioned it to them. They just thought, well, I better go to North. Which is a reasonable assumption to make if the GP literally doesn't treatment planet. What's our treatment planning like? What is our process? Where do we do it? Where do we talk about it? In the operatory, I could do a whole podcast. Why? That's a giant mistake. We talk of. What do we say? Who says it? Do we talk about only money and insurance? Another giant mistake. Do we talk about value? How do we say it? How much detail do we go into? How do we know how much detail to do? What visual tools are we using? So a lot of it for me is learning the treatment planning process so we can comprehensively treat patients. Would you imagine this, Wes? How well would every dentist in your business do if they comprehensively treatment planned every patient and every patient said yes to all of it?

Problem solved.

Right? We'd all, I mean, look in your own dentist listening along, look in your, in your software and run your report or whatever it is and your, your treatment plants and see what people didn't do.

I'm gonna have a lot of dentists retiring at mid-50s, early-50s.

What did they not do? And then we have to ask ourselves, why now? Does that mean I had 100% case acceptance? No, I didn't. But does that mean on big cases we had higher levels of case acceptance? The difference between a practice to that's busy and not making enough money. Here's the difference. I'm gonna tell you in a very, in one sentence, the difference between a practice that's so busy but not making enough production and a practice that is the exact same practice of making production is two cases a month. It's two $20,000 cases a month. That's it. If you could take a $40,000 number and add it to your monthly production every month, consistently, you have a different practice period. But we don't present our own treatment plans because we're too busy. I'm doing air quotes right now. We're too busy. So we leave it to somebody up front who's not trained as a dentist, who primarily talks about insurance and money and what's covered and we're not covered. So to me, taking about all the processes that we do, literally from the moment the patient steps in the door until the moment they step out of the door, what is our process? How do we say it? Who says it? Where do we say it?

And then what we do is we get these larger cases and what we do is recommended putting them together. Let Me ask you this, Dennis. Listening. Let's say you diagnose three fillings in the upper right, three fillings in the upper left, and three fillings in the lower right. How many points is that going to be in your office? Be honest, mere moment. It's usually going to be three. Because we practice quadrant dentistry because somebody at dental school told us that's the way we're supposed to do it. Bull owning. Did you know that every patient that walks in your office, this is a practice. I mean, a study done by Gordon Christensen, a respected researcher in dentistry, he found that every setting up and breaking down a room for a restorative appointment, all the stuff that we use during that appointment, independent of the actual materials used, I'm talking about disposables and time. It's about $24 per restorative appointment. 24 bucks. So if a person needs two fillings and I do them simultaneously, it's 24 bucks. If I do them separately now, it's 48. So when I have a patient that needs 12 fillings, you know what? They get a long appointment. One. I have found patients actually prefer this because they don't have to drive there twice, Get a babysitter twice or whatever they need to do twice. Take out time off work, especially if you're doing.

If you're doing in house, crowns with.

CEREC or worry about it twice, which is a big thing. People have fear. So to me, combining treatment, I do not take treatment apart. People go, oh, left side, right side. Let me ask you this. Oh, we don't. We shouldn't be numb in both lower, lower jaws. I've heard that a million times on both lower sides. How many times do you see an oral surgeon take out all four wisdom teeth versus one at a time? Or even more ridiculous, how many times have you seen a cardiologist doing a quadruple bypass? One coronary artery per surgery? It doesn't make sense. I call that deconstructing. We deconstruct in dentistry too often. Let's reconstruct. Hey, you have some issues going on. What I need to do is get an appointment to get you in and get them fixed. Let's go ahead and have you take the morning off work or whatever you need to do. And when you're done, you won't need to come back again until your next cleaning. I think to think that's a very strong narrative. So by combining treatment, I'm not reinventing the, oh, the patient's late. Oh, the patient has to go to the Bathroom. I better give her a call. All this stuff occurs less often if we have less little appointments. So if you look at your schedule for tomorrow and you find that it's. There's 14 people on the doctor side, something is wrong. Either you're not treatment planning comprehensively or you're breaking stuff up. My best days were one or two patients in the morning, one or two in the afternoon. And my ultimate best days were one patient all day, one patient all day, bunch of veneers or whatever. So to me, a lot of the solution to PPOs isn't bad mouthing to PPO, it's saying, yeah, I'm making a little less money per item. I get it. How do I reduce my costs and increase my efficiencies so it doesn't hurt me as badly? Now that $20,000 case I was talking about, Wes, in California, where we sit in most states, they have what they call insurance reform laws. What does that mean? That means if something isn't covered by the ppo, it's not a covered service. In other words, they reject that service because it's a non covered benefit. Does that make sense, what I'm saying?

Yep.

We do not have to utilize the PPO's fee.

Okay? For example, veneers, okay, we can charge UCR in California for a veneer if the BBO expressly does not cover that process. Cosmetics. If it's accepted this I say accepted exe. If it's an exception, to me, this is another place we can work. How many times are we having cosmetic conversations with our patients? Truly, how many times are we saying, hey Wes, you know what? I think you look great, but I think your teeth could look better? How many times are we saying never? Are we waiting for the cosmetic case until it walks in, identifies itself or are we identifying for the patient? I did many, many Photoshop workups I didn't do myself. I have a guy use, a guy named Eddie Corrales, who is a good friend. Excellent. Unbelievable. Lab technician. To work up cases using a Photoshop type thing. I'd take a little movie or photos, he would work up a Photoshop and I'd show them. Out of 100 that I showed that maybe 5 did the case. 5% case acceptance, right? So to get what, when we percents can be deceiving, right? Wes, you know this. You're a numbers guy. 5%, that's not very many. What if I showed a thousand people that. That's 50 cases. Now I probably don't have a thousand people to work up I was exaggerating. But if every time I see somebody with teeth that look dingy or ground down or messed up, I'm going to have a cosmetic conversation with.

And how long does that, so you have the conversation and then it's a matter of taking pictures and then, so what do you usually do a mock.

Yeah, I'll say, hey, you know what? You're, and I don't mind, especially women, because if you have a conversation, women are a little more concerned with their smiles. And it's just the way it goes. I, I, I'm sorry for an old timer and just, it doesn't sit well with some new.

That's what they do, some of these.

Younger folks, but that's the way it works. Most of the years are done at women. So by the way, if you look at the money spent in this country on cosmetic surgery, generally, you know, head to toe, it's staggering. It's staggering how much money is spent on cosmetic surgery. People want to look better, they want to look younger. So if I have a person come in my office and I say something like this, hey, you know, Mary, I'm just making up a name. Hey, Mary, you know, I, I think you look great. I love what, I love, I love what you've done with, with your hair. I love your outfit, whatever. It depends on how close you are to these patients. Now, you don't want to be weird. You want to, you don't want a weird amount. But I just want to, you know, as your dentist, it's my job to identify something. And may I have your permission to say something that may be a little bit, I don't know, a little pokey to you?

Right?

Yes, of course you have my permission, Doctor. Well, your teeth could look better there. It's out there in the air. I said, and Mary, I didn't mean to say that you look ugly or terrible. I certainly don't mean that at all. I just think that a smile, a beautiful smile can change your can light up the whole face. Would you like me to show you what your smile could look like with a little bit of dental intervention? A lot of them will say, no, thank you. I'm perfectly happy with this enormous gap. But people will sometimes say, yeah, I'm cool with that. Say, how about I just take one picture? It's no charge. Let me just take a couple pictures and I'll have a friend of mine do a little Photoshop on you. There's no charge. And, and we'll look at it next time or I'll send it to you in the email. Women will stare at that silly Photoshop until they convince themselves it's necessary. So to me, appealing to the larger part of the case matters. How many dentists walk in the room and they go, ah, this person's on Delta. Therefore they suck. Therefore I'm just going to go over as quickly as possible. No, I don't feel like replacing that amalgam. Delta's probably going to reject it. Screw it. You know what? You're looking good. We'll see you next time. And to me, that's not doing a service to anybody Are you looking to.

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Yeah, and so much of what you're talking about, I'll step in here, is talking about communication to the patient, of course. And a picture is a form of communication. Words are a form of communication. And I know for me, and I think this is just human nature pretty much for everybody, which is when you see what the results can be and it's. It's visual, it's. It's present, or it's communicated really effectively. Suddenly what I thought I didn't need or. Or even want, it becomes appealing to me because it's very clear what the outcome is. And I think sometimes it's hard for people in general. I've had to learn this in my own business to try to paint a clear picture of what is the solution, what is the outcome, what is the value of something that I'm recommending to somebody to where they feel a. An incentive. They feel something sort of working up in their emotions and in their psychology to say, you know what? I think I really, really need that. Because a lot of times people don't even know what ultimately they need or even know what they want until they see what the solution can actually look like.

Of course, and those are the big cases. But going back to the littler cases, right, the treatment planning process that we described a bit earlier, what do we do? What happens in your office? For those listening to this particular podcast, what happens in your office? You diagnose a crown. You go in and hygiene and you look and go, this tooth needs a crown. It's cracked. What are the next steps? Generally speaking, that person will go to the front desk and somebody at the desk or near the desk will go, okay, Joe, I looked up your crown. You have Delta insurance. The insurance covers 50%, so your out of pocket is $450. That does sound about right. And making up the numbers, but that's what the conversation, in my own experience.

In many ways, yeah.

So that is the absolute wrong conversation to have at first because the only thing we talked about was the cost. We never talked about the benefit. We never got to know the patient. We never sat down with them and said, hey, let's take a look at this intraoral photo. We never allowed them in their mind to decide, I need to be fixed, I need to be helped. All we told them is you, who were clueless about this 60 minutes ago. Now we're going to have to spend money. What if it's a lot of crowns? What if it's $3,000? What do we do? Same process. To me, it's coming out of the mouth of the not doctor. There's no discussion other than money. And this is something I go over extensively with officers when I work with them, which is, how do we say it, where do we say it and what do we say? Now, of course, we don't hide the fees. We talk about the fees. And by the way, doctors listening, even worse than that is printing out a list of items. Let's say they have several fillings, a couple of quadrants of scaling and a crown. My day to day stuff, Right. If I print that out from my practice management software, whatever that might be, they all look kind of the same. They look like a list of words and numbers and lots of numbers. Insurance write off insurance payment, overall payment, patient portion. There are count, look at the treatment plan for a few items like I'm describing and count how many actual numbers are on that treatment plan, how many dollar numbers on the treatment plan for five, six items. You'll probably find 50 numbers. They don't get it for in offices I work with, we don't use that at all. I have devised a separate form, so to speak, on the Internet that they fill out. And that's what we give the patient. We give them a case fee. Now this requires complete narrative training of how we talk about it. We don't hide it. If somebody says, I'd like the line item stuff, but most people don't. Again talking about deconstructing. Like, Wes, I see in front of you is a microphone that you're talking into.

Okay.

About how much does a microphone like that cost?

This one is a very nice one. So this one was, I think around $450.

Okay, so. And to describe people, to try to paint a word picture, I'm seeing a silver microphone, a nice big professional looking microphone that's also on a stand like a, like a, like almost a tripod. And it also has a piece of felt in front of it, so I guess we don't spit on it or whatever.

Creates a smoother vocal flow. Yeah.

Okay, so does it. Various parts to that microphone. And one thing I see on the stand, Wes, you'll agree, is a little dial where I can tighten it or loosen it to attach or make it taller or shorter. Do you see that dial?

I do.

How much was the dial?

Oh, well, it came with The. Well, this thing. I don't know. It was 12 bucks.

So the dial was. You bought it separately?

I bought it separately.

How much was this little stand part right here?

That stand right there was probably 30, 40 bucks.

Okay, but there's a lot of parts of the stand. There's also this.

There's the cord going into the microphone.

How much was the cord?

The cord was probably 12 bucks or so.

Okay, how much was this little screw? Did that screw come with it or is that screw separate?

That screw came with it. This.

But how much is just the screw?

Oh, I don't know. 10 cents.

Right, but the fact is we don't know and we're being silly here.

I don't know.

And to try to bring it to something at home. You have a toaster in your kitchen.

Yes.

When you bought the toaster at Target, let's say it was 30 bucks. How much was the. The little handle?

No clue.

How much was the leg? How much was the burner? See, in the real world, when we buy something, it's made of parts, even if we buy a service that's made of parts. Have you ever gotten new brakes on your car?

You paid for the brakes on your car? How much do brakes cost?

I don't even remember something.

Let's say 500, right?

Yeah, sounds about right.

Can you explain to me exactly how the braking system of your car works generally?

Not really.

Yeah, I know there's like brake fluid and something squeezes, but.

Exactly. A disc.

I get it. Generally I'm a human and I understand, but I don't have to have an acute understanding of every detail of breaks in order to be a consumer purchasing breaks. In dentistry, we give this detailed breakdown. We deconstruct the treatment plan. You know what I sell in my office? I sell mouth health. Right now, the mouth is unhealthy. There are several processes we need to do to make it healthy again. That will take us two visits. Each visit will be about X hours. The. The cost for your dental treatment will be $850. We've already taken into account your insurance, and there's a little more that goes to that. But never do I break it down into procedures unless they insist upon seeing it, which is extremely rare. Because once we develop the. The narrative, they don't care. They just want to know, where's my health going? Now some things will. Will break out. Like if they're an ortho case, we'll break that out separately but restorative. Why are we breaking it down into individual teeth? Don't the teeth work together to be a mouth? Just like all the parts of your microphone, all the parts of a toaster work together to be a toaster. So part of what we do is we break stuff down and patients go, well, I want those fillings because they're well covered by my insurance. But that line right there, that crown one I don't want. And we give them this kind of line item veto. That doesn't make sense in a health, in a health context. Not going to be healthy again if they only do a portion of recommended treatment. Now I'm assuming here we're recommending ethical treatment. Obviously we're not over treating. But what I'm trying to get at is when we work with insurance, we have a tendency to focus on what the insurance doesn't cover or does cover. I really don't care. Patients just want to know what's the bottom line. So we'll figure out the top line and the bottom line. Just like you do in your, in your accounting company. What's the top line? The total cost for your procedures is $3040. I'm so thrilled that you have Delta insurance. They really going to help you out here after we take into account two factors. First of all, your top line was $3,040 just by having Delta insurance. Just by having and being a member that reduces your fee to 1900. You've already saved $1500 by just being on this insurance. That is fantastic. Now they're going to pay for a portion of that too. Maybe here's the thing, that $1,500 or $1,900 savings that you had, that's guaranteed, you are guaranteed to get that as a member of Delta. I'm also going to try to get more for you. I'm going to send in what's called a claim. I was doing some air quotes right there. I'm going to send in a claim. On that claim. I'm going to ask for additional money from Delta. I've estimated they should be paying it assuming they do what they're supposed to do, about $400. So that'll save you even additional money on this procedure. Bringing your bottom line to whatever the bottom line is. So think about it doctors. If you do a crown, let's say you do six crowns and they have a fifteen hundred dollar maximum, right? And your normal fee for your crown is eighteen hundred dollars. Making it simple here. And Delta's fee is a ousand.

They'Re saving 800 bucks a crown just by being on Delta alone. Just by being a card carrying member, they're saving 800 bucks a crown times six. They're saving eight times six or $4,800 just by being on Delta over our UCR. Agree or disagree so far with the math?

Agree. Yeah, good math.

Now their maximum is probably 1500. They probably spent a little of that. But let's say they could get 1500, which had a greater impact on their bottom line, the amount they saved on being a Delta member or the additional money from a claim.

Right. It's obvious.

Yep.

So if we present it in that context to the patient, hey, I'm so glad you have this insurance because your fee would have been $5,000 total. Even with. I'm going to go. Go ahead. And just by being on Delta alone, you get it for 2000, I'm going to submit a claim and try to get even more for you. Now, I can't guarantee that part. Sometimes Delta will do exactly. Usually we'll get what we think we're going to get. Some as it could be more or less, I'll let you know. But I'm going to go for it. And I think we're going to get about 400 more, 800 more, whatever the amount is. If we work in that context, number one, we eliminate a lot of the arguing get in the office about estimates because they think that they just focus on that. We want to focus on the greater savings that they're getting just by being a member. Now do I like having that write off? We call it a write off. I never say that word in front of a patient because people think a write off is a good thing or you got a write off. Congratulations. You own a business, therefore you get your car for free too. That's how people think. There's a famous Seinfeld episode where they talk about writes.

Yeah, the tax write offs.

You don't even know what a write off is. What Seinfeld says to Kramer. So I don't like taking that huge write off of X dollars that we discussed. I don't like the feeling that I've had to lower my fees. You see, Wes, I voluntarily signed that contract in good conscience. I have to do. That's honesty. So if I have to do it, I'm going to get some mileage out and I'm going to present it in such a way the patient goes, oh, that's great. I'm so glad I have it. Rather than going, what? They only pay this, I want them to pay that.

Most of the time people don't even pay for their insurance because they get it through work or if they're paying for it, it's low. Look, you saved nineteen hundred dollars. You already had a huge benefit from Delta. And I'm going to try to even get you that paints you in the way that you're now their ally as opposed to saying, hey, you know what, you have insurance that really sucks. I'm gonna have to send a claim in. They probably won't cover it. If we start to get into that attitude, do you think a patient wants to go back to the negative place or do they want to go to the place that celebrates how great they're doing on this? So to me, there's a psychology to it.

There's a huge psychology. Here's if I summarize all this because I've just, I've just let you run with this because the, this is a.

Space I'm so passionate about.

This is a space that you know you're passionate about it and you've worked up a model, a framework which is entirely different than the standard framework that dentists often approach insurance with inside of a dental practice. And if I try to summarize it, tell me if I'm wrong about this, but that you're letting the driver of the solution to the patient health be driven by what is the desired outcome for that patient? And not by, not by the insurance. Agreed. And what the insurance covered. If you let, if you let. Yeah, if you let the insurance be what originates that whole sequence of dominoes in that discussion? It's a very different set, it's a very different sort of pattern and flow than if you start with what is the end in mind, regardless of insurance. It's completely not even included in that conversation. And you're just focusing and painting this solution and helping them visualize it and feel, feel the emotion of it. So that with that emotion then they will make decisions around their finances. And you start with that domino and then it sort of flows back to the ultimate domino of here's what your insurance covers. It's. And you're saving this much with it and we're going to do everything we can to even get more out of that.

And the thing too is you have to remember, just become because somebody carries insurance doesn't make them a second class citizen and they shouldn't be in your office. I was in an office just yesterday. You know who I'm talking about. And on all of the insured charts they have an orange sticker. They're still using paper charts. They have an orange sticker right on the chart. It's as if they've been tanged. Here's the thing. Most of my insured people in my office, at least where I live, are what I would call white collar workers. These are a lot of computer folks, engineers that work in these tech companies. They make plenty of money to afford optional dental care, et cetera, above the max, so to speak. Dental care, they can afford it. But if we make it about, if we, if we treat them in such a way that, oh crap, here comes this guy on Delta. Therefore, I'm gonna have all sorts of issues. And therefore then they're gonna feel that, see, these people didn't become computer scientists and engineers because they were stupid. They did it because they're smart. They're gonna feel the negativity. They already have a negative view of dentistry. Walking in the door, they had a negative view. Why are we playing into that? Why are we becoming. We're, we're. It becomes a, like a self fulfilling.

Process, reinforcing that perception.

This place is going to suck. And then we tell them how much it sucks. They already don't want to be here and now we're going to make it worse instead. Let's celebrate. Got great news for you. Dr. Did mention some things that are wrong. Let's go over that now. The treatment planning conversation. The treatment planning narrative. This is something I spend days on, not hours and certainly not minutes. So what I've said today is just scratching the surface. Don't use these tricks yet. I'm saying if you're listening to this, I. If you listen to this podcast, it's about attitude. If you're going to take insurance and you're going to sign that contract, then for gosh sakes, act like an adult and have a good attitude toward it that you're helping people. If you don't want, fine, then just don't tear up the contract. Yep, it's as simple as that.

And I think what's driving that you made this statement, this is almost like a, like a, like a theme that I think an office should live by and think by and breathe by, which is a dentist drill. Doctors treat patient health. Viewing yourself as a doctor and the patient health, if that drives the way you communicate and what you're sort of trying to help the patient see, then you're acting as a healthcare provider concerned about their health. Everything else is ancillary to that. Everything else is ancillary to that.

Let me tell you a quick story really plays into this. If you don't mind. Quick one. We used to have a patient. I'm not going to mention his name. Well, his name was Dan. I'm not going to say his last name. So this patient came into our office and he had Delta insurance. He's an AC guy. He's about 5 4, long gray ponytail, unshaven, always bare feet, and always looked like he was almost homeless. And he'd come into our office and he only had the front six teeth in the upper and lower arches. That's it. No back teeth. And so you know what happens, doctors, when you don't have back teeth? You're using your front teeth like back teeth, and they don't do well. And I ended up putting a crown on one of them, and then it broke. And then a root canal and then a post and a bigger post. And I just kept trying to save the day with bigger and bigger composites because this guy, you know, he can't afford it. Anyway, one day we're at the office and he comes in and he leaves from his appointment, and he comes back in and says, I've got a dead battery in my car. Can anybody jumpstart my car? And of course, everybody looks at me now in our office, and I think, you've been to our building. We have underground enclosed parking for the doctors. Everybody else has to, you know, fight for a spot in. In the lot. So I'm like, I had a really nice car at the time. I don't want to bring my car out to this guy and have him give me crap about two. But he really needed it. So I go downstairs into the basement of the building. I get my car, and I drive out to the parking lot where he's waiting. He's waiting next to an orange Lamborghini with the doors up, right? Or the door up. It was. It was a Lamborghini. For those that are. Those that are Lamborghini people, it was a Lamborghini Murcielago. And it was. It was day, glow orange. And I got out and said, dan, this is like my dream. I'm a car guy. This is my dream car. Holy moly. You know, can I sit in it? And then we're talking about cars. Turns out he has two of them. He also has some other fancy cars. He has a collection of fancy cars. So I finally said to him, dan, I need. I'm in the wrong business. You know, congratulations on all this. What. What do you do? And he said, well, I own. And I'm not going to say the company, but I own what turns out to be the largest air conditioning company in San Diego. This is a company with hundreds of employees. He's the owner. I had judged him, so I never offered him to fix his back teeth, get some dental implants. I knew could have paid for it. I would have offered. He carried Delta, right? So I just never did anything, which is dumb. This is years ago. Anyway, so I went back in and I told the story to everybody. And I told everybody, you know what? This is it. We're changing our ways. When this guy comes in, next time, we're going to offer him the best. Everybody gets the best. You know, I was wrong. I'm growing from this experience. There are our patients. Just because we think they can't afford it doesn't mean we should judge them anyway. So we all resolve we're going to do this. And when Dan came back, we would. We would fix it. Well, Dan never came back. I never saw him again. I don't even know if he's still alive. This is a long time ago. I just never saw him again. And I still regret that. It almost sounds like a story that's too good to be true, but it's absolutely true, and it makes me sad. We, as Dennis, we look, oh, this person has Delta. He has an orange sticker. Therefore, I'm going to treat him in a different way. Doesn't make sense to me. Most people are willing to step outside their insurance and get what they need to get. If we build proper value and we just don't, we give up before we start the fight. So to me, that's. There's the answer to insurance. So if you were hoping for a special trick, how we can use a certain code to make more money, I'm sorry I failed you. What I'm saying is we just need to look in the mirror and change the way we act toward these patients.

I think this is probably a podcast that people should listen to more than once because there's so much content packed into this past 58 minutes we're going on right now. And so thank you, Bob, for so much good content. Let me just. You know, sometimes I listen to a great podcast and I just want to, like, take notes and summarize it for myself. Let me do my best to summarize some of these things. That's sort of our takeaways out of this. Talking about, can you thrive at a PPO practice? Your answer is yes. Play by the rules, and you can still thrive in a PPO practice, even with the pressure of downward reimbursement rates that have existed. And here's how you do it. Number one is you have a better hygiene health program focusing a lot more on perio and not just the pros. Is DI state not. No, I stated that wrong. The perio, not just the scaling and root planning.

We actively check patients for periodontal problems and if they have them, we solve.

Great.

That sounds so dumb, but you'd be surprised how many doctors or hygienists just don't. You know, they say the average in. I'm sorry, I know you're in a summary mode here, but quickly they say that Ada says the number is like 60% of people in the US have some sort of periodontal disease. Let's assume that a lot of that 60% are never going to go to the dentist. I think a dental office should have what I a percent perio, what I call a perio percentage. In other words, a percentage of the time that hygienist is working should be about 30% of that should be on periodontal procedures and about 70% should be on non periodontal procedures.

Got it. Okay. I've stated much better than me. Clearly not my space there. Let's talk about dollars and I can compete there.

Well, Perio brings in the. It helps the patient and it brings in the dollars.

And, and these first, really there. There's 1, 2, 3, 4, 5, 6 things. But these first five are all about leverage, which is how do you get the job done in a process that doesn't involve you standing right there by the patient? Leverage, leveraging resources and leveraging people. Number one, better hygiene program. Better hygiene health, Better hygiene system. Number two, CEREC CAD cam, preferably technology. In your example that you gave Sarek, you had two cerecs running a lot. You don't have to be standing by the CEREC when it's doing its own thing.

I train people to stand by the CEREC who get paid less than I do.

You train people? Yes. Number three is efficiency. You focused on simplicity and in organized, what I'll call it an organized assembly line around everything else surrounding that patient and that treatment. Number four is team. Specifically in this case, train your assistant to do more, to do more so you can do less. Again, we're leveraging. Number five is front office. A great front office staff that knows how to focus on new patients, reducing cancellations and keeping the flow of patients coming and going. That's number five again, that's leverage. You can train that and then you can step away for the most part. But then you had full treatment planning. And I'm going to say with one through five, the leveraging. One of the phrases I think about a lot is this concept of delegate and elevate. You del, you, you help create the system. And I always say a good business owner, a good CEO, has to create. They don't just do, they have to create, and that's creating processes, frameworks, workflow, scripting, whatever. But they have to create that, train people to follow it, and then they stand back and they let their team elevate and learn. And you gotta be incredibly tolerant of mistakes. You have to be really tolerant and don't make your team feel guilty for making mistakes. Help them feel like that is a natural part of the process of growth. And I've just come to believe you have to build a tolerance for mistakes to be a good business owner. So delegate and elevate. Just such an important concept of leadership. And then this last one you mentioned, this full treatment planning. My, you know, my thought on that is you and I were talking offline about, actually a different podcast. We were talking about how in dental offices you got your fixed costs and then you got your variable costs and most of your dental office expenses, including your debt, are fixed cash outflows. And that amounts to like 80, 90% of all of your expenses. And then you'd have 10 to 20% that are variable, like your dental supplies and labs. And they're variable just means that they go up or down based on your production. Everything else stays pretty much the same for the most part, regardless of your production. Those are called your fixed costs. Well, if one through five, which is just this good hygiene program, good recall, your assistants doing their things, you're doing your crowns, you're doing your CAD CAMs, you're, you're using good technology that's like your bread and butter. If that can meet all of your overhead costs, your, your, your fixed and your variable costs. And then you tag on two of these full treatments and all you have as a cost associated with those two treatments, let's say they're two $20,000 treatments, like you mentioned, is you got supplies and labs. That's it. You got 10 to 15%. And so 80, 85% of those two things is going straight to your bottom line to help pay for your needs, your kids, education, your lifestyle, your travel expenses, your future self debt, your new car.

Exactly.

But that extra amount is like, that's what makes that the world of difference. So it's like 1 through 5 is just covering. It's covering your basic nut and bolts and you're doing well. And even in a month where you don't have those two treatments, or maybe you have one, you're still doing okay. But then you do those treatments, those big treatments, and you're. That's. That. That changes your whole world at that point. That was my main thought on how you laid that, laid that out. Did I summarize that? Well, for a listener, you know, in.

In every dentist, business owner, a dentist who's in private practice, in every dentist's body should really be three different Personas. Three different people all wrapped up in one. There's a dentist. By definition, a dentist fixes teeth or gums or whatever. If you're not good at that, there are courses available to help you improve yourself. Then there's a doctor. A doctor looks at a human being and says, how do I improve this person's life? Well, I'm going to comprehensively look and see what we can only affect a small portion of the body. I'm not going to fix their toe, but I can figure out how doing things for in their dental health can improve their life. For example, let's say somebody is 65 and lost all of the teeth and all they have is dentures or a few teeth left. If somebody somewhere had intervened like 30 years ago and really helped that person, maybe they would have had a different path. That's a doctor. How can I get this person on a path to health? Things we forget all the time. Night guards, fluorides, advice. How do we help this person prevent dental disease? The third thing, dentist, the doctor. The third item is the leader. A leader doesn't just lead his staff. You're paying them. They're going to do what you say. You lead the patients. I'm leading my patient toward making better decisions. How do I be that leader? How do. What narratives do I use? Can I be a leader with my drill? I'm not going to be a leader with my fluoride or my night guard. I'm going to be a leader with my narratives. So for those that are private practice dentists, you need to be all three. And this is a mirror moment. Look in the mirror. How good am I at being a dentist? Am I really good? Am I pretty good? Do I need help? How good am am I at being a doctor? And how good am I being a leader? If you're going to give yourself a 10 out of 10 on all three of those, you don't need any help and you're Killing it. But be honest, if any of those isn't working out, you need help. Somebody can be your mentor on any of those three and help you. This is the space I occupy. I had one office you know about not saying any names. He was just not a good leader. He was a nice person, but just didn't know how to lead his patients and staff in the right direction. I've been working with him for a year, and gosh, we found a leader. And their production is almost doubled at an established office that he's been there for 16 years. Doubled in a year. So what's the magic trick? It's finding those three people in that one body and making them all work. So all the specifics we talked about with PPOs, that's a little teeny portion of it. There's a billion other things, but hey, you asked about PPOs, so that's where we went. But a dental practice. There's plenty of money to make in dentistry without charging junk fees. What I call junk fees. Oh, I'm going to charge an extra lab fee. I made this one out of emacs. That's a junk fee. First of all, it's disallowed by most PPO contracts. But forgetting that that's not the way we make. We make money in dentistry by being good dentists, doctors and leaders. If we can do that, the sky's the limit. I promise you in this area, at least a solo practice with one doctor and two hygienists, which I think is a nice ratio, can easily do 161 7, no problem. I think they can actually be capable of doing well over two. If you're not, you have to figure out which of those three. Where we're failing or where we're struggling. Let's call it. And strengthen that party. Make sense?

It does. And I will confess then that I'm convinced that the with. With. With the right approach, with the right leadership, with the right th. Those three things. And I think a lot of energy and motivation, I think is needed in all of this. Of course, sort of laced throughout.

You have to care.

Like your whole existence has to just exude leadership. Exude being a healthcare provider, the doctor exude being a great dentist, where you just lift up people's confidence and belief in you. But I think with that inside the framework of a ppo. Okay, sold. You can be successful.

If you hate being a dentist, just don't be a dentist anymore.

Yeah.

And you're a smart enough person, go pursue another avenue. And by the same token, if you hate PPOs, don't participate.

And I will say that if you want to. Yeah. If you don't want to participate so much, all of this still applies even without the ppo. And it's saying that you can be successful in the PPO with these things, but you got to be good at these things. If you're somehow in a fee for service, maybe you're not as great, but you're getting sixteen hundred dollars on a crown. Well, there's some forgiving, there's some forgiveness there that you can still be fairly profitable.

But look at the economy right now, Wes. Everybody talks about we're headed to a recession, we're headed to problems. Who knows where we're headed? You know better than I do. I'm sure people are going to be tightening their belts and if somebody's carrying Delta, they might go, you know what? I have a lot of a dental expenses. I'm going to look around and find somebody in work. This might just happen. I think there's a certain danger to not having Mommy Delta there as our safety net.

So I like working with Delta, working with MetLife. Do I like that they take some money away? No, I don't like that at all. But I like that I have a good relationship. I'm feeling comfortable with it and it helped me have a very good living.

Yep. So here's where I'll negotiate with you. My final solution to our little debate is, is it good to have PPOs in your practices? It is. It is.

You.

Yes, you can, you can succeed. I will add to that that if you remove the PPO and did all this and were that busy, you'd have a $3 million practice, which would be amazing. And those practices do exist. And maybe in certain areas it's easier to do that with competition and dentist per per capita GP ratios, things like that. I'm always the visionary thinking about the ideal. But you are absolutely right, Bob. So many great points. I love the layout, I love the communication. We are definitely going to do more podcasts in the future is my hope, because I think there's a lot of subjects that we can delve into and people are just going to be super edified and learn from these conversations and everything. You have to.

Thanks so much for having me. I don't mean to be preachy about this. To those listening, you're passionate. I don't want to be an evangelist about it, but I do want to say, you know, we have a pretty cool profession. We have the capability to help people and make plenty of money doing it. Stop screwing around and just do that. It's just so simple. It's nauseating. That we can do a filling that takes us 15 minutes, get paid a hundred bucks for it. It's crazy. Let's just keep doing it.

Yeah, why not? Points well made. I love it. I love it. Thank you again, Bob, for joining the Dental Forum podcast. Thanks for having me and for being a good friend.