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Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Digital Esthetics. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.
Benjamin Franklin famously opined, “A penny saved is a penny earned.” And while that chestnut of wisdom is certainly true as a guiding philosophy for success in life, it can be taken too literally. What may seem like smart cost savings measures can take a more deleterious toll on the doctor’s practice than doing it “the right way” in the first place.
1. Not training on practice management software
When the office gets new practice management software, it might seem like the software developer is just trying to squeeze as much money out of the practice as they can by proposing training for a couple thousand more dollars. However, passing on this opportunity is a mistake.
“When they get the costs broken down: Here is the cost of your software, here’s the cost of your training, a lot of them will think, ‘Gosh, I don’t need to pay for the training,’” observes Dr. John Flucke, DDS, Technology Editor and Chief Dental Editor for Dental Products Report. “The training costs are not a couple of bucks. Training is probably $2,500, maybe a little more. And a lot of them think, ‘Well, for that, we can fumble around a little bit and push buttons. We’ll figure it out. Most people in the industry now are familiar with software, and a lot of people might think, ‘If I’m an Eaglesoft user and we change to Dentrix, how much different can it be?’ It’s a combination of thinking that they can figure it out and the idea of saving that money, but what they don’t realize is that every day, money leaks out from under the door because of the inefficiency.”
“One of the biggest frustrations I have is with a dentist who invests in practice management software, but because the in-office training for that software is another $2,500, they don’t invest in that,” adds Linda Miles, CSP, CMC, the founder of Miles Global. “‘We’ll give them the manuals.’ That’s why 90 percent of the practices are only using about 20 percent of the capabilities of their practice management software.”
While some might not want to pay the premium for even basic training, Dr. Flucke brings in extra training opportunities.
“I do just the opposite,” says Dr. Flucke. “In my practice, we will try and pick a subject a year, and we do a retrain.”
He asks staff what they think they need additional help with. For instance, even though he’s been an Eaglesoft user since 1994, his practice took advantage of a refresher course.
“We paid for a trainer to come out, and we spent an entire afternoon just getting retrained on things we might not know about that have been improved upon the last couple of years,” says Dr. Flucke.
2. CE only for the doctor and not the rest of the team
Every professional knows that once they leave school, they’re not done learning â such is particularly the case for dentists who work in an ever-changing field. While it may seem cost effective to only pay for continuing education opportunities for the doctor, it’s a mistake not to include the rest of the team.
“It’s absolutely the key to their success,” says Miles.
And expecting to take part in the informational opportunity and just pass along the information is simply not effective. For example, Miles spent some time consulting with a husband and wife who had worked together for 20 years.
“When I got there, there were seven wonderful ladies who had never been anywhere,” says Miles. “They’d never taken them. They’d always gone and created a husband/wife vacation out of it. And those women were like sponges in a fountain, ready to learn, working their buns off, never getting the praise and appreciation they deserve, because if you’re not doing your job to the fullest, your doctor and spouse can’t bring that back. They have got to be involved in training.”
Miles recently worked with American Dental Assistants Association, and was surprised to discover that membership is not as high as it should be.
“Out of 370,000 clinical assistants and administrative assistants in dentistry, they only have 6,000 members,” says Miles. “There should be 60,000 paying members. The reason is that the doctor doesn’t see value in paying their dues, which comes with a magazine, insurance for professional liability, and accidental death. It comes with 70 online training modules and it costs less than $170 a year.”
Miles notes that a big fear in providing CE for office staff is the concern that it will mean additional costs to the doctor down the road.
“Dentists are so fearful of ‘If I get these women out of the office and train them, and they become certified dental assistants, or in some states expanded function dental assistants, they’ll ask for $2 more an hour,” says Miles. “It becomes cost-prohibitive. They’re stepping over dollars to pick up dimes. If I can increase my doctor’s productivity $10,000 to $20,000 a month, am I not worth $2 an hour more?”
3. Having a family member who is your “technology expert”
Doctors also look to save money with the office technology component of their practice by turning to a family member “who knows computers.” But what tapping Cousin Bryan saves can become expensive, especially due to the specific nature of dental technology.
“When push comes to shove, that person might not be available because they have a full-time job, and they may not be as well versed in dental software and the technology that goes with it as somebody who does it day in and day out,” observes Dr. Martin Jablow, DMD.
Someone with a general knowledge of computers can set up an office network â but seeking out a person or company that specializes in dental offices is worth the investment.
“A generic tech person can set up an office network â that’s not a difficult thing to do at this time,” says Dr. Jablow. “But they’re not going to be well versed in the dental software, and there are both local, regional, and national companies that are dental- oriented and can provide that service. In many cases, the initial network may be installed locally, but the dental teams come in â or can even remotely come in through the server and install the software, do the updates, and do whatever they need to. They just need somebody in the office occasionally to plug something in.”
Utilizing a service that specializes in dental office technology can keep the practice in the most current state of dental office technology. Complacency can cause problems down the road for the dental practice.
“Some of them give up their tech support completely,” says Dr. Jablow. “They stay on old copies of software, because they say, ‘Well, it works for me, and why should I continue to pay somebody hundreds of dollars a month to support something that still works? They don’t necessarily see the value in it, because if everything is running perfectly, that’s great. But if you don’t keep up your support and are running old systems, that’s not necessarily good. If your hardware breaks down, who’s going to come fix it? Like everything, it’s an insurance policy, and you have to determine what your insurance needs are.”
4. Buying a piece of technology and not doing training
Buying a new piece of equipment can cost thousands of dollars and â more than likely â it will come with a manual, so why bother to pay extra money for training?
“There are some people who are qualified and can do that,” says Dr. Jablow. “An example might be: If you’ve been using lasers for years, and the latest and greatest comes out, the need for additional training might be less than somebody who’s never picked up a laser in his or her life. But in many cases, the last step is always training, and that’s the step that’s given up. People don’t always do that, because it seems to take time out of the office, and it just creates a situation where they think they can do it.”
Failing to take advantage of that training can mean not getting the most out of your investment.
“They may not get the most out of the technology then, but they think that they’ll grow into it,” says Dr. Jablow. “Training is an ongoing thing. It should always be considered a necessity, not an afterthought.”
The necessity for training applies to both hardware and software, but for different reasons.
“In software, training is really important, because if you’re not using the software properly, there’s a loss in efficiency,” says Dr. Jablow. “If there’s a piece of hardware you’re not using completely, that may be a loss of income. It might take you longer to do it, and you might lose efficiency.”
That is not to say that you need to spend more time and money than is necessary to get the training that you need.
“You should consider what you want to do, how much do you want to take advantage of what it offers, and what’s the learning curve?” observes Dr. Jablow. “That all comes into play. Training is the key to everything. You have to justify your costs and expense and what the return on that investment is.”
5. Reusing single-use products
While there are some products that are obviously only suited for one time uses â like cotton swabs or gauze â some doctors try to cut corners by reusing one-time- only products that they think are durable enough to be recovered.
“For some folks, I think there is a mentality of ‘Anything that saves me money makes me money,’” says Dr. Flucke. “It’s unfortunate that people do that, but they do.”
Reusing single-use products presents problems on two fronts: Some items are not durable enough to be utilized for two or three or more usages; and no matter how well the product is cleaned, it will likely not be clean enough to use on a second patient.
For instance, a few years ago, Dr. Flucke conducted a course about lasers, and one doctor approached him, asking about the reusable tips for the laser. The tips are one-time use, and cost $5 to $6 each. This doctor balked at the expense, asking if the tips could be soaked in disinfectant and reused.
“You’re going to lose some efficiency, especially with lasers. You’ve got energized light passing through them,” observes Dr. Flucke. “There was a lot wrong with that. For starters, the idea of reusing something that you cannot truly sterilize on another human being. He had no concerns about that at all.”
The logical way to combat that expenditure is to pass it along to the patient as a cost of doing business. However, that practice is still a foreign concept to some doctors.
“If the tip is $5, raise the price $5,” says Dr. Flucke. “You use brand new stuff every time. You’re doing what you’re supposed to be doing â ethically and morally â and you’re not losing money doing it. For some people who are hardwired for the numbers, they just cant wrap their heads around that, because they think if they raise the price $5, I can reuse single-use products and keep $5.”
6. Using non-precious material and billing as precious
Doctors can get extra reimbursement from insurance companies if they use less expensive, base metals for restorations, but charge the insurance company as if it were a precious metal. The problem with that practice should seem obvious.
“It’s insurance fraud,” says Charles Yenkner, executive director of the IdentAlloy/IdentCeram Council. “Normally the reason for doing it is that they get a higher reimbursement rate from the insurance companies for a precious or a high noble crown or restoration than they would for a predominantly base one.”
Doctors who do it might be able to get away with it because the practice doesn’t seem to be high on insurance companies’ priority list.
“I had some discussions a couple years ago with the insurance companies,” says Yenkner. “It doesn’t seem to be a lot of concern on the insurance companies’ part, but they’ve told me that a very high percentage of the restorations that they reimburse the doctors are for are high noble. And I know that what they are reimbursing for is higher than the usage of noble metals as a share of the market.”
Doctors may engage in this practice because of a sense that there isn’t much difference, functionally, between the two types of materials.
“I don’t know that you can make a definitive statement that using higher noble metals in every case makes a higher quality restoration than base metals,” says Yenkner. “I think most people would agree that would be correct, but from a purely clinical standpoint, I don’t know that there’s any data or anything to back that up. It certainly is a misrepresentation. Noble metals cost more, they tend to have better tarnish and corrosion resistance, so I would think that most dentists would agree that using a high noble restoration is better.”
While there might not be a functional difference between the two categories of materials, there can still be deleterious effects on some patients.
“There are a certain number of patients who have allergic reactions to nickel, which is the prime ingredient in the predominantly base metal alloys,” notes Yenkner. “About 10 to 12 percent of the population has nickel allergies, so you really should know what you’re putting in the patient’s mouth.”
Whether the patient does or does not react badly to the material, it is still bad business practice.
“It’s definitely fraud, and if it’s a case where Medicare is involved, then it’s Medicare fraud,” adds Yenkner.
7. Not maintaining your handpieces
The workhorse of the dental practice is the doctor’s handpiece, and like a musician’s instrument, maintenance is critical, and a mistake to overlook.
“People don’t think about it, but it is simply a matter of spraying some oil into the device, running some air through it to make sure the dose of oil is thinned out, and that’s about it,” says Dr. Flucke. “But people get in a hurry. They don’t think about it. The easiest and most effective way to make sure you are doing proper maintenance is to use an automated handpiece maintenance system. There are many brands on the market and they are designed to perform the maintenance cycle perfectly. Investing in one of these systems is one of the smartest things a practice can do.”
Dr. Flucke recommends having extra handpieces to fall back on in case of emergency.
“I’d rather have 10 handpieces and only use eight as opposed to only having five and needing 10,” says Dr. Flucke. “Then you’re trying to turn and burn with your sterilization cycles, and that sort of thing. That’s when you get sloppy. I don’t have time to spend the five minutes to make sure that we get maintenance done before we put this handpiece in the autoclave, because we’re running behind. And that’s one of the things in the profession that a lot of people do: They run behind. That’s when they get sloppy.”
Beyond finding one’s self in a time crunch because the handpieces haven’t been cleaned properly or aren’t running at optimal efficiency, poorly maintained handpieces have the potential to cause harm.
A few years ago, the FDA put out a bulletin about electric handpieces not being properly maintained. The gears in the heads of handpieces were getting gummed up and burning patients.
“An air driven handpiece would have failed, but an electric handpiece, because the motors are strong and have more torque, could overcome that gooeyness,” explains Dr. Flucke. “The heat generated from overcoming that goo was causing the heads to get too hot. The head of the handpiece would rest against the inside of the cheek or on the tongue, and people were getting burned. They couldn’t feel it because they were anesthetized. Sometimes it’s not an issue of efficiency and keeping your devices up and running; sometimes that equipment can cause you problems from the standpoint of patient safety.”
8. Buying equipment off eBay
If you are in the market for something â just about anything, really â it can readily be found on a secondary marketplace, like eBay. While eBay is a good place to find hard to locate items, it can also be a place to find equipment â both new and used â on the cheap. While this can be an attractive source of low cost equipment for doctors, it’s a bad idea.
“There are really two things we see in a secondary marketplace, eBay or Amazon,” says Jim Aycock, director of marketing and business development for Midmark. “The first are legitimate products that are built by recognized manufacturers, and those products are being resold outside of the approved dealer network. The second are devices that are coming in from overseas and are not FDA-approved. These are pieces of equipment and materials that are not being tested by anyone and then being put into use in a clinic with some impact to patient care and the safety of all.”
The appeal of getting equipment at a much lower cost is certainly appealing â and seems to make good financial sense. But acquiring that equipment outside of normal channels is fraught with unforeseen problems.
“When it’s our products being resold, one of my biggest concerns is if the buyer will be familiar with the proper use and operation of the device,” says Aycock. “This is important so that patient safety is not compromised. For many pieces of equipment and materials, it could literally be the difference between life and death for a patient and/or staff members.”
Beyond simply getting started with the equipment and materials, if something goes wrong, there is nowhere to turn for help.
“Our caution to clinicians is to remember, when you buy something through a secondary marketplace, there’s nothing a manufacturer can do when something goes wrong,” says Aycock. “Things can be great for 90 days or so, but on that day when something breaks or there is a failure, our hands and the dealer’s hands are tied, because we and/or our authorized dealers weren’t involved in the transaction.”
9. Using free e-mail to send PHI between patients and dentists
It might be easy for doctors to use free email services â like Gmail â to transmit confidential patient information, rather than paying for a premium service. After all, the email just has to get from here to there, right? Unfortunately, it’s not so simple. Health Insurance Portability and Accountability Act (HIPAA) rules and regulations are strict and come with serious penalties.
Dr. Flucke spoke to a provider of encrypted email services for dentists that has a full time staff member whose job is to be an expert on HIPAA law. Doctors are doing themselves a disservice by being ignorant of the laws.
“No one really understands HIPAA, except this very bright lady, and it’s her job,” says Dr. Flucke. “There’s a couple of dangers: Sending information that has a lot of information about another person. If that’s not encrypted or secure in some way, never mind the law, it’s morally and ethically wrong. The other part of it is, as this law becomes more and more enforceable, as the Feds figure out what they’re going to do, I look on the situation like OSHA was in the late ‘80s/early ‘90s. There were some people who got hit with some pretty hefty fines on OSHA things, and before that happened, everyone said, ‘Oh, that’s never going to happen.’”
To illustrate the seriousness, Dr. Flucke tells the story of a dermatology office that had one of its laptops stolen.
“I believe the practice settled with the Feds for $150,000,” says Dr. Flucke. “In order to get the attention of the providers, those enforcing the laws will do stuff like this. You have to make some examples out of people to make the industry sit up and take notice. I look for a dentist who, at some point in time, is going to have that happen.”
The Feds aren’t the only source of penalty â there’s a potential for patient blowback.
“One of the specifics about the law is, if more than a certain number â and it’s not a huge number â of people are involved, you have to notify all of them individually that there was a data breach,” says Dr. Flucke. “You have to notify the media. You have to provide some type of credit monitoring for them. Of course, once the media is involved, once they get ahold of a story like that, the negative publicity could cause serious harm to an office’s reputation. I think a situation like that could really torpedo some good people whose hearts are in the right place.”
10. Having your spouse working at the practice
Having one’s spouse working at the practice has the potential to cause problems, both at home and in the office.
“There are dental practices where, if it were not for that spouse, there probably wouldn’t be as much success, because nobody cares about the bottom line than the spouse, who is the co-owner of this business,” notes Miles. “However, 30 percent of the spouses in the practice are a total disasters.”
In one case, Miles saw the doctor’s spouse coming and going at will, causing resentment among the other staff.
“They can’t depend on her,” Miles told the doctor. “She leaves when your children are in a play at school. When the team’s children are in plays, they can’t leave. You’re showing favoritism and this is ruining morale. It’s costing you a lot more than another employee.”
And while bringing a spouse to work might seem like an opportunity to save money, it has the potential to cost more money. Miles tells about one doctor’s husband who thought it would make sense to give up his job and go to work with her. This also created flexibility for their family and their two young children. But in the end, it didn’t work out.
“He had to take another job, because this poor woman is on every insurance plan in dentistry,” says Miles. “She produces between $70,000 and $80,000 a month â which is a $1 million a year practice â working her fingers to the bone, but her write-offs are $30,000 a month, which means she is a non-profit practice.”
Getting off that office’s insurance plan, and getting his own at a new job, wound up saving them $12,000 a year.
“They think they’re saving money, but sometimes the team members totally resent the spouse, and the morale is pulled down by the spouses who are micromanagers, who are not team players,” says Miles. “It doesn’t really save that much money, because accountants will recommend that your spouse, whether they work in the office or not, should all be on the payroll, because if the spouse goes to these dental meetings and isn’t on the payroll, then their travel expenses are not write-offs.”
Working together also poses threats to the couple’s relationship if there cannot be delineation between the office and home.
“I tell my clients, ‘If you work together, have a line of demarcation somewhere on your drive home. Have a point where you will stop talking about the office and concentrate on being a couple,’” advises Miles, who recently had an award named after her within the Speaking Consulting Network brand she began.
Saving money wherever possible is the hallmark of a responsible business owner. However, there are many cases where doctors are doing themselves a disservice by trying to cut the corners too tightly.