Recession-ERA Recalls

March 21, 2012
Renee Knight
Renee Knight

Issue 5

You’ve likely noticed a change in your patients. The patients who come through your practice are more selective these days. the economy has made that a necessity for most americans, whether you’re talking about the type of dentistry they choose to go forward with or the type of car they opt to buy. Americans, in general, don’t have the discretionary income they once did, and that means expensive treatment plans aren’t in the budget.

You’ve likely noticed a change in your patients. The patients who come through your practice are more selective these days. the economy has made that a necessity for most americans, whether you’re talking about the type of dentistry they choose to go forward with or the type of car they opt to buy. Americans, in general, don’t have the discretionary income they once did, and that means expensive treatment plans aren’t in the budget.

They’ve changed their thinking about what is elective versus necessary dentistry, and they don’t want to pay a big dental bill out of pocket or add it to their credit card debt if they don’t have to. They’re more cautious about what they’re spending their money on, and that means you and your team have to work a little harder to ensure your patients receive the dental care they need.

To thrive in this environment, your practice has to adapt to this new patient-a patient who wants to spend less and save more. You have to change the way you communicate with your patients about treatment, you have to offer more flexible payment options for patients who continue to struggle financially and you have to look at more economical alteratives when it comes to the materials and techniques you use.

The recession may have officially ended in 2009, but many of your patients are still out of work, or worried they will be soon. Many don’t have insurance, and if they do their plan doesn’t cover as much as it once did. They have economic pressures and concerns they didn’t have before the recession hit in 2007, a reality that likely will continue for awhile and may even become the norm. This may make your job more challenging, but it’s also an opportunity for you to take a step back, look at the systems you have in place and make positive changes that will not only help your patients, but also your practice. This is the time to focus on getting back to the basics, and doing your part to educate patients about what’s best for their dental health.

“It’s all about building the relationship with patients and communicating with them,” cosmetic dentist Dr. Marty Zase said. “Sometimes dentists have a tendency to be standoffish. If we remember doctor means teacher and teach patients what they need to know, they have an understanding of why treatment is important.”

Changes in spending
When money gets tight, consumers have to make changes to survive, and studies show that is happening, from Americans buying less expensive brands to making a commitment to save more money (see “What’s happening to the consumer,” below). The health care industry has seen the effects of that, with U.S. health care spending only growing 4 percent in 2009 to $2.5 trillion, the lowest growth rate in 50 years, according to the latest annual National Health Expenditure Accounts (NHEA).

What does that mean for dentistry? Spending for dental services declined 0.1 percent in 2009 to $102.2 billion compared with 5.1 percent growth in 2008. Out of pocket spending for dental services, which accounts for more than 40 percent of dental spending, declined to 5.5 percent in 2009.

These numbers and this new consumer mentality is exactly why you have to up your game. If you don’t, you’re going to get left behind.

“Every recession people pull back and these spending practices become new habits,” consultant Dr. Dean Mersky said. “We also have the threat of a new norm in our national economy. It’s very possible unemployment will have a new higher normal. It’s possible that as companies scale back on benefits, fewer dental benefits will be a new normal.”

Wants vs. needs
A majority of today’s patients are driven by what they need rather than what they want, cosmetic dentist Dr. John Weston said, so if you present treatment plans as purely cosmetic they’ll most likely say no, or maybe later. If their insurance doesn’t cover it, in their mind, that means it isn’t a need-even if you know it is. But if you educate patients about what will happen if they don’t do anything and provide real evidence of “need,” they are more likely to accept treatment. It also helps them see why the treatment you’re recommending is necessary. Times like this can help get you back to the nuts and bolts dentistry you likely weren’t doing as much of when the economy was thriving.

“It’s just about education,” Dr. Weston said. “We’ve always approached it that way, but we’re taking it to a higher level now, and it’s been great for my practice. Now we’re doing more of what we probably should have been doing. We’re doing more smaller cases now and fewer larger cases (compared with before the recession).”

Many patients are looking for practices that offer third party financing, and CareCredit has been one of the most popular options for nearly 25 years. Here, we talk with Bete Johnson, Director, Business Development, on what CareCredit can offer your patients and your practice.

DPR: How would you say the recession has changed the dental patient as far as what they’re willing to pay for out of pocket?

Johnson: The recession has impacted patients in several different ways, which has changed the way they view and pay for their dental care needs. Though the S&P is the highest it’s been in 3 years, consumer confidence is now at only 63%* (90% is considered a healthy level*).

First, as employee health care and dental benefits have been reduced, more patients are paying out of pocket for their care to bridge the gap between their insurance coverage and the cost of the care. Second, many people have adjusted their financial priorities and spending behavior because of job changes or budget requirements. As a result, patients remain hesitant to tap into their savings or use any remaining available credit on their consumer cards and may not have access to previous lines of credit (i.e., Home Equity credit lines). Instead, patients are prioritizing their spending on more fundamental needs and saving more ‘just in case.’

In this ’new normal’ environment, patients are coming into the practice knowing what they are willing to spend-and what their non-cash resources are- before they even know the dentist’s recommendations based on a clinical examination. They’re taking more time in between hygiene visits; and elective, cosmetic dentistry is not being readily considered, if at all.

DPR: With more patients struggling financially, how can dentists help them get the care they need?

Johnson: Offering a dedicated line of credit for health care expenses through a program such as CareCredit is truly an extension of the level of service a doctor can provide. As part of the broader conversation before the clinical examination, including a discussion about what to expect during the visit and verifying patient information, communicating with patients about financial options enables them to focus on the dentist’s recommended care and not on how they are going to pay for it.

During the financial conversation, it’s helpful to discuss the cost of care in terms of both total treatment fee and estimated monthly payment, giving patients as many choices and as much information as possible to determine what best fits their individual financial situation. It also is important for the dental team to clearly communicate the value of the dentistry needed and the consequences of delaying or declining care.

DPR: Can you tell me a little about CareCredit and how it works?

Johnson: CareCredit is a health care credit card for every member of the family, including pets, and has provided health care payment options for nearly 25 years and for more than 20 million consumers.

Patients complete a short credit application and credit decisions are provided in seconds. Patients can immediately use CareCredit for their elective treatment needs. CareCredit is a revolving line of credit that can be used at any of the nearly 150,000 health care practices that offer the program, including dentistry. Patients have a set credit limit and, as they pay down their balance, they can use the line of credit again for additional care for themselves or their entire family, at any of the health care practices that offer our program. CareCredit offers two basic payment plans to meet a patient’s financial needs.**

DPR: What are the benefits of using CareCredit for patients? How does having a revolving line of credit benefit the entire family?

Johnson: The biggest benefit for patients is the ability to get the care they need without delay and conveniently pay over time with monthly payments. The most popular patient choice is a No Interest plan that charges no interest when account holders make their required minimum monthly payment and pay the entire balance in full within the promotional period. CareCredit enables patients to retain their savings for emergencies and their other credit cards for day-to-day expenses. And the revolving line of credit I described earlier helps the entire family access care with no need to reapply.

DPR: What are the benefits for dentists?

Johnson: For dentists and their teams, CareCredit makes financial conversations easier by providing another payment option. When patients have multiple payment options to choose from, it helps them access the care they need.

The provider’s ultimate responsibility is to the patient. CareCredit helps providers focus on the important job of diagnosing and delivering care, and making sure the patient understands the recommendation, by lessening the financing and administrative tasks that come with managing their own payment plans. Another benefit is the financial relationship is now between the patient and CareCredit, reducing team stress and the likelihood of patients delaying care or hygiene because they have an outstanding balance with the practice.

DPR: Has there been an increase in the number of patients using CareCredit and offices offering it in recent years?


Johnson: Founded in 1987, CareCredit was initially offered to doctors to help their patients pay for new dental implant technology. Continued advancements in technology, and procedures that are often not covered or fully covered by insurance, have created new choices for care, increasing the demand for financing options. The number of practices offering CareCredit grows steadily every year.Today, CareCredit is offered by 86,000 dental practices, nearly 7 out of 10.

Two of the primary reasons doctors add CareCredit include: patients request CareCredit by name, which is a strong indicator of increasing patient preference to use CareCredit; and at the recommendation of one of their colleagues, which indicates high satisfaction with the program.

DPR: Is there anything else you’d like to add?

Johnson: One of the most unique aspects of our program is our Practice Development Team. These dedicated professionals educate dental teams on how to integrate financial options into the practice and provide valuable, customized reporting, including benchmark data. Many practices tell us they value the training, best practices and growth ideas their representative provides, based on their experience meeting with other dental teams on a daily basis.

In addition, our dedicated CareCredit Practice Support Center is available 24/7 to answer questions and support practices with practice enhancing resources. We also have a dedicated Healthcare Customer Service team that treats patients as the practice would, with respect. As a result, our cardholder satisfaction ratings are very high, with more than 96% indicating they would recommend CareCredit to a friend or family member.***

Most importantly, we are partners with our practices that offer our program, working together to help more patients access care and providing a variety of payment options patients need and appreciate.
Your readers are invited to call 800-300-3046 to speak with one of our professionals for more information about our program.

* The Conference Board Consumer Confidence Index, March 2011
** No Interest Plans for 6, 12, 18 and 24 months that charge no interest when account holders make their required minimum monthly payment and pay the entire balance in full within the promotional period.
-- Extended Payment Plans for 24, 36, 48 or 60 months. These plans carry an interest rate that is more competitive than most bankcards and feature a fixed, equal monthly payment and a longer term.
*** Bi-annual Cardholder Satisfaction Survey, October 2010

The phased treatment plan
The patient sitting in your chair may need thousands of dollars worth of dental work, but that doesn’t mean you should overwhelm that patient with a dollar amount he or she likely can’t afford. That’s the fastest way to get a patient to say “No, not now.”

It’s your job to help patients prioritize treatment, Dr. Zase said. Make it OK for them to postpone some of the needed treatment, as long as they’re not being neglectful. Listen to your patients about their financial concerns, and let them know you understand and will do what you can to make treatment manageable. Talk to them about what really needs to happen now and what can maybe wait six months or a year. Give them all their options and help them see the value in what you’re offering. Remind them that if they don’t do anything, they may end up spending more to fix serious problems you’re giving them the chance to prevent.

When presenting a treatment plan you need to be realistic, said Tom Limoli of Limoli and Associates (limoli.com). Don’t diagnose the patient based on the number of crowns he needs and expect that patient to accept treatment. Slow down and make it digestible for your patients. Focus on building relationships and trust, not just your bottom line.

“The basic treatment planning dentists learned in college has always been you remove first, then you repair, then you replace. That can’t happen until you stabilize the patient. Once you stabilize the patient, and it’s not getting worse, then you begin to repair, then you move to replace,” Limoli said. “Patients are looking for a partner in health, and unfortunately they’re not getting it from a lot of dentists. A patient walks in the door, sits in the chair and the doctor says you need a crown here a crown here and that will be $4,000. The patient may need those crowns, but that patient has been to three other dentists who told him the same thing. Patients are looking for somebody who will treat their overall health but who will treat it in a way they can make work for their budget.”

Know what to say
When you deliver the treatment plan in phases, Lois Banta, of Banta Consulting, said the first phase always should involve attaining life-long oral health and comfort. Discuss with your patients how they can keep their teeth over a lifetime, and again, spend time listening.

“When talking about phased dentistry, you have to listen to what your patients want so you can tell them what they need to do to get there,” Banta said. “If you tell them what they need before they’re ready to listen, they’ll come back to how it’s too expensive.”

Once it’s your turn to do the talking, it’s important to know the right thing to say, Banta said. Often, if you say something just a little differently, you’ll get the message across and get patients thinking about why they should get treatment, not focusing on why they shouldn’t.

Be sure to use benefit statements when talking with patients about treatment options. Explain to patients who aren’t sure if they really need that crown what the health and financial consequences may be for delaying care. But don’t leave it at that. Let them know you want to make sure they have the least amount of out of pocket cost possible. Help your patients see the long-term benefits of receiving the care now versus waiting until the problem gets worse.

When patients leave you with a maybe because of financial concerns or because they want to talk out their options with their spouse, you or your treatment coordinator should get them out of “maybe” and actually get them to “no,” said Amy Morgan, CEO of Pride Institute. The patient will feel better but not stalked, and while you’re getting “no” for now, you have the opportunity to find out what the real obstacles are that need to be transcended to ultimately get to the “yes.”

“If a patient says ‘I want to do cosmetic dentistry but I’m not certain about insurance or keeping my spouse in his or her job,’ look at that patient and say ‘What I hear you say is it’s no for now. What are the criteria that we need to help you get to yes?,’” Morgan said. “Even if yes isn’t for two years down the line, having an agreement that the treatment plan is essential and that the practice is going to work with the patient to get to yes opens up the opportunity for positive discussion and flexible options to get the practice and the patient where they want to be.”

Flexible financing
Not a lot of patients have dental insurance these days, and even if they do, that insurance isn’t going to cover much for patients who are in need of pricey cosmetic work. Phasing treatment by doing what’s most important first helps make the cost more manageable for the patient, but that alone often isn’t enough. Many patients need some sort of third party financing option, Periodontics Clinical 360 team member Dr. Richard Huot said, whether that’s CareCredit (see “What third party financing can offer,” p. 63) or the ability to use a credit card.

Many doctors are afraid to talk about money with their patients, Dr. Zase said, but these days you simply must have that conversation. Dentistry is expensive, but there are many organizations willing to help finance dentistry, many of them interest-free if the patient pays the amount in a certain period of time.

Dr. Weston offers outside financing in his practice, something he said his patients use every day. He looked for a lender with more lenient conditions to make it easier for his patients to qualify for a health care loan, enabling patients who don’t have the best credit to still get the treatment they need.

“The nice thing about outside financing is the dentist office gets paid upfront and the finance company collects the fee from the patient. You get the money up front like a cash paying patient,” Dr. Weston said. “The company charges a small fee for their services, but it allows you to treat those patients who were going to walk out your front door, so that’s a pretty big value.”

But for some patients, even these financing options aren’t enough. They’re just not able to get a loan, no matter how flexible the conditions. That’s where internal financing becomes an option, though it’s not a popular one with many dentists. But with more offices moving to e-communications and online bill pay, there’s a great opportunity to create dynamic, customized financial solutions to help patients afford care, Morgan said.

How can you make this work in your practice? You have to create systems for financial arrangements and collections that are modern and that actually satisfy the patients you’re delivering the dentistry to, Morgan said. You have to understand your existing system’s strengths and challenges and look at what’s working and what isn’t. It also means clearing out any old debt.

Many doctors are hesitant to offer internal options, Morgan said, but if you have the systems in place it’s not as risky as many think. If you can help patients set up automatic payments online, the risk of them not paying each month decreases significantly. And you don’t have to worry about draining practice resources to prepare bills and spending money to stamp envelopes to snail mail them. Today, it all can be done with an automatic system that you monitor through e-blasts and texts.

The economy may be down, but that doesn’t mean you can’t invest in your practice. Keeping up-to-date on the most current technologies will not only attract patients to your practice, it will wow them while they’re there, Dr. Marty Zase said. Cutting-edge technology, like lasers, is a way to generate patient interest and position yourself as an innovative practice focused on patient care. Featured on the right is the Odyssey Navigator Diode Laser from Ivoclar Vivadent.

“Learning effective skills to create strong financial systems to allow patients to get dentistry and get the practice paid is an art form,” Morgan said. “It does require training, re-invention of processes and thinking differently, but strong financial options are very often going to be the make/break for success.”

Still not convinced this is a viable option for your practice? Banta suggests having patients who don’t qualify for third party financing make payments before their procedure rather than after it. These patients pay a small monthly fee, which ensures you get paid and helps them get their confidence and their credit life back, not to mention the dental work they need to stay in good health.
Even for patients who are out of work and struggling financially, there are options you can offer to help them get the care they need. It just takes a little creativity and flexibility.

“There’s a way around every obstacle, you just have to look for the way around it,” Banta said. “You have two choices, look for a way around it or you can wallow in it. I choose the latter. It’s a lot more fun.”

Know what’s expected
Offering high quality service isn’t enough these days, Limoli said. It’s expected. Patients have high expectations and will not spend their dollars at your practice if they don’t feel valued. Now’s the time to give that little bit extra to let your patients know they’re in the right place, to help them feel more confident when they do make the financial commitment to a treatment plan.

There are simple gestures you can make to take your practice above and beyond, Banta said. Have a new patient coming in this week? Give him a call the night before to let him know you’re looking forward to meeting him. Take him on a tour of the office when he arrives the next day. Keep patients of record informed of the latest advancements offered at your practice and services you’ve added for a more personal touch. Give patients a call after a procedure just to see how they’re doing, and be sure to send the same patients home with a TLC kit filled with Hershey Kisses, Tylenol and chicken soup. 

Banta calls this focus on customer service a secret weapon that will keep patients loyal to your practice, no matter their financial situation. Decay and cracked teeth aren’t going away because the economy is bad; patients are stressed and likely have more dental problems than they did when times were good. Upping your customer service, which includes offering flexible financing and searching for more affordable alternatives, will make patients want to spend they’re money with you, even if that isn’t today.

“Many behavioral psychologists and researchers have indicated people make decisions based on emotion,” Dr. Mersky said. “The behavioral economists believe there is no rational thought to what drives the economy, it’s mostly emotion and that’s what creates bubbles and swings. This type of thinking has weaved it’s way into marketing and advertising and underscores the importance of the customer experience in the decisions they make…We all know patients aren’t checking margins and don’t understand contours and bonding and all the things we do, but they do understand how they feel about the experience.”

Don’t let your stress show
Sure this is a stressful time for your patients, but it’s also a stressful time for you. You and your team members are working extra hard to get patients to accept treatment plans, and you’re worried about how the struggling economy is affecting your practice.

Patients base your level of expertise on how well you treat them when they walk though the door, Banta said. If you’re stressed about the economy, or anything at all, you can’t let your patients see that. It only creates a negative scenario for the patient, who will be less likely to accept needed treatment from you and more likely to visit the practice down the street. Remember patients aren’t just more selective about the dental treatment they’ll accept; they’re also more selective about who they’ll let do it.

“It’s a constant work in progress. Have team meetings often on addressing issues early, and strategies in place for helping patients get what they need. If you don’t have a positive attitude it will eat you alive as well,” Banta said. “You have to get more creative with how you handle stresses that come along with that. Like increasing customer service, building relationships, changing your body language and increasing verbal skills to help patients have a very positive experience in your office.”

Offering patients more economical alternatives is a great way to get them on board with a treatment plan. They’ll like the fact that you’re working with them so they can get the care they need, and if the bill feels more manageable, they’ll be more willing to take it on. It also goes a long way toward gaining their trust.

Through skills he’s learned as a member of the American Academy of Cosmetic Dentistry, Dr. Weston offers direct bonded cosmetic treatments, a great alternative for patients who are looking to save money but still want high-quality results.

“I’ve done more of this in the last three years of practice than in the last 10 years,” he said. “Patients are looking for affordable alternatives and I have developed the skill to do it. Pursuing training that expands your skills in the area of direct bonded restorations for anterior teeth is huge. For about half the price of porcelain I can do a direct bonded restoration that will look great. It’s durable and a nice long-term transitional option that’s affordable. Patients come to my practice and I offer them a direct bonded option and they go for it. We can treat a patient who was forced to say no everywhere else because the doctors only offered a lab restoration option.”

There are also lower-cost options and procedures for posterior teeth, including doing more direct bonded filings instead of porcelain inlays. Using direct materials allows you to do more quadrant dentistry, and done well, may even last as long as porcelain.

There also are ways to help make implants more affordable, Dr. Weston said. These days, he’s doing more stock abutments than custom abutments, and instead of doing an implant per tooth he’s placing implant bridges. He’s also using his patients’ transitional partial dentures  as surgical guides when he can, and he’s slowing down the treatment time. More patients are opting to extend their healing time to five or six months and then maybe start the crown the following year.

Dr. Huot also has noticed that if patients need an implant, they’re putting off the final restoration as long as possible. Patients are getting the prep work, and then they’re waiting.

“The advantage we have is we can have an implant placed and it can stay like that for an indefinite amount of time. It’s important for dentists to work as a team with their patients. Let’s at least get the first part done and revisit it later,” Dr. Huot said. “But I don’t think there’s a real clear alternative to implants like dentures. That would be drastic. People might go with bridges, fixed bridges where they’re just replacing one tooth. The insurance company may not pay for an implant but will pay for a three-unit bridge for a patient who lost a tooth. You can make that an alternative choice even though the implant is the better treatment. It’s almost like a fall back option.”

It comes down to looking for ways to make treatment more affordable, whether it’s by changing the procedures you’re doing or by talking with your lab about using more economical materials so you can pass that savings on to your patients. It may take a little research, talking with colleagues and taking extra classes to be able to offer your patients these options, but the extra work will be worth itwhen you turn an, “I’m not sure I can afford this” to a, “Yes, when can we get started?

Discounts can help clear debt                                                                 

Before you set up a new financial system, you need to collect any outstanding debt, Pride Institute CEO Amy Morgan said. Send an amnesty letter to patients explaining you’re very sensitive to the fact that many patients have been struggling with financial concerns for quite some time, and you never want patients to compromise their care because of lack of affordability. Let them know to create new options, you’re looking at old accounts and offering a 10% adjustment. Announce that you’re becoming more flexible financially and explain what options you have available. This not only gives them a bit of a discount on their current bill, but lets them know you’re willing to work with them on any future bills. 

Low-cost electives
Just because a patient isn’t willing to take on a pricey cosmetic case doesn’t mean he might not be willing to consider low-cost elective continuing care or restorative options that will help him care for and preserve his health, Morgan said. The continuing care department that offers whitening, sealants, fluoride treatment, clear aligners, lasers, sleep therapy and anti-microbials is providing low-cost solutions that will help patients remain invested in their dental care.

“There are many, many options and if patients feel like the options you provide are customized to their needs from a financial and treatment point of view, the more likely they are to commit,” Morgan said.

A strong recall program also is important, Dr. Weston said, because prevention is key not only to keeping patients healthy, but to keeping costs down as well. Having a healthy patient base means when patients are ready for cosmetic dentistry, there aren’t many, if any, problems holding them back. It’s important to help people protect their dental investments, and to make sure you catch problems while they’re still small.