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AUDIO - HSP #146 - Bill Rossi
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VIDEO - HSP #146 - Bill Rossi
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If you don't know what to look for, it's so easy to get lost in your stats. Listen to Bill Rossi tell you exactly what you should know about your practice's numbers!
Bill Rossi has over 25 years of experience in dental practice management. He and his associates are actively involved in the ongoing management of over 240 practices.
advancedpracticemanagement.com
apm@advancedpracticemanagement.com
(952) 921-3360
Howard: It is a huge honor, to be interviewing Bill Rosse today who is the most, you own Minnesota. I mean you are the most down to earth, real world, practiced management consultant, who's been knocking it out for, how many years have you been doing this?
Bill: Almost thirty, I think thirty-five Howard.
Howard: How many people have told you, you look just like Mike Detolla?
Bill: I think Mike Detolla looks better than me, I must say.
Howard: I don't know, you're both two charming, handsome individuals. I love both of you guys. You really are the real deal, and what I love about you is you have the big picture philosophies, and you have so much, nitty-gritty operations and logistics details. I want to ask you the first question, and we'll get to the talking points and all that stuff, but my first question is something that a lot of people are thinking. The big, four-thousand pound elephant in the room in managed care, and how many years have you been doing this, you say?
Bill: Thirty five years.
Howard: You and I are old enough that when we started back in the day, there was Orthodontic Centers of America on the New York Stock Exchange, and everybody thought that they were ...
Bill: Jonathan Bentle up here. Bunch of those.
Howard: They were saying back in nineteen-ninety, that someday all Orthodontists will work for Orthodontic Centers of America, and then they fell apart and disappeared. There were a dozen on NASDAQ, and then they all fell apart. They were gone for a decade. Now they're all back with a vengeance, and a lot of people are saying, that the way to fight, or to compete against these guys, is you've got to have a niche market, and you shouldn't take insurance, and you should be this boutique practice. First of all, how big of a market presence, is big corporate, multi location dentistry, and ten years from now, are they going to be double in size, or are we going to see the same fall out again? How does an individual dentist, compete, and build a thriving practice, when you've got a corporate chain across the street from you.
Bill: Yeah, we're seeing it here. I don't know, I think it might be twenty percent. I think it's less than that probably, and I try not to predict the future, because I have to stay in the moment. I have to stay with what is real, and not what I think is real, and will be real. I'm looking at my client data and stuff, and we have Aspen Dental's up here, Midwest Dental Centers, which came out of Wisconsin, and went from eighty to one-hundred-fifty centers in a while. Pacific dental has four units here. Heartland's breaking into the area. Most my guys are doing okay, I kind of see our goal, as getting them the same advantages of professional management, but they each keep their individual thing. I would not go elitist, to me everything's a matter of balance. You don't go too crazy on the PPO's, you don't go elitist. Most my guys are middle of the road guys, that want to do twenty or thirty percent better.
They don't want to change their personalities, or their religion, or their lifestyle. They just want to have a pride in practice. I kind of say to corporate dentistry, bring them on, because you have an advantage over the pharmacists who we know have been kind of wiped out. Is, who hands you your pills is not that big a deal. Who sticks their fingers in your mouth, and you have to see over and over again, is and I think that will help save us.
Howard: Well I mean, it seems like every new patient I see, has already seen five, or six dentists and they're not happy, so how is the corporate entity going to stop that. I mean it really comes down to the doctor-patient relationship.
Bill: Yeah, and corporations, I mean, they do hire dentists, and some of those like Metro Dental and Heart Dental, are big group practices. You know we use corporate dentistry, and I know it's not accurate but everyone knows what you're saying when you say corporate dentistry. Tell you who's a great associate here is someone that's a Park Dental, or Metro Dental, refugee. They've worked there one to five years, they've got speed, they've got perspective and they come out and they're perfect associates. I look at them as sort of boot camp, for some great associates.
Howard: You manage two hundred and fifty practices, do you ...
Bill: Over two hundred and twelve practices, with about two hundred and seventy five to three hundred dentists. Depending on how you count full time equivalence.
Howard: You've got about seven thousand dentists listening. If someone wants to get your help, do you do any state or do you do a region?
Bill: My whole motto is based on the idea that management's a process, and so instead of flying all over the place and coming in, God, I'd go crazy, if every week, Wednesday I was on manual three, paragraph three, during the same week, over and over again. I would've gone branch-dividend thirty five years ago. Set the building on fire, run out and then run back into it. That's what I would have done and so we are regional. Now in special missions like on a PPO exorcism, or some kind of things like that. We'll get on airplanes, so I have a client or two in Detroit, and I get around and stuff, but we're mostly regional folks.
Now, I'm on a mission with the PPO stuff because I want a level the playing field with dentists, and I can do that a lot of times by phone. They don't have to get into some big consulting deal, so we do national type stuff like that. The other thing I'm big on, is a thing I did for Virginia, and Ed and you guys for, which is cynical calibration. Which to me is the ethical foundation of great dentistry, whatever type of model of practices. Those are my two national missions, but my day to day management is pretty regional.
Howard: Let's go right to the PPO, money's the answer, what's the question. How does a person analyze a PPO because my pet peeve, your talking about your mission. My pet peeve is that they all run run their office with what they call, quote, "A management information system." It doesn't even have an accounting package ...
Bill: I know, it doesn't have revenue and expense sides.
Howard: How insane, I mean why is that? It is the dumbest thing in dentistry. It's the single biggest crime in dentistry because that schedule knows, that Dr. Amy takes one hour to do this procedure. The PPO she just signed up for, has the fee, we should know if your doing your payables, receivables, rent, mortgage, insurance and all those professional things, we should your hourly cost. I know Amy, and she's smart, and she got A's in Calculus and Physics, and Chemistry and BioChem, and if you told her, "Look, you do this, and you'll lose twenty dollars on every filling." Well she said, "Well then I ain't doing it." But she doesn't know that data. So how does a guy like you, if I'm listening I'm driving to work right now and I say, "I want Bill to analyze my PPO's." What are you going to do? First of all, how much does that cost? He calls you and how do you figure that out.
Bill: It cost's nothing to call me, usually again I don't believe in mincing words, a couple grand usually is what I do when I do a PPO assessment on a practice. Here's what I've found, trying to analyse in great detail, the cost or which codes are being paid what doesn't change the course of action. When an analysis doesn't change the course of action, you over do the analysis. What happens is often, when I get someone I look at them and I look at the penetration of the various PPO's to see how deep they're in with the various PPO's.
Then it's a matter of balance. Let me give you an example of this, for our east coast client that had an accountant, I was working on a Met Life exorcism, and dealing with some other PPO's there. Now, don't sue me Met Life, it could be any kind of thing or whatever. I had the accountant then, this is Alan Shift, who did a good job of this. He surveyed, I don't know, like sixty dentists on the east coast because I don't know have a feel for that in the mix, and I got this here, and I have a point, I'll get to it. Here's the deal, fifty four percent of the offices were with Blue Cross Blue Shield there. Forty six percent, Met Life, fifty one percent Aetna. Fifty eight percent Sig99, and according to the other percent, other sixty one. About twenty six percent of the offices in this area were with all the plans, and about twenty one percent were with none of the plans. Then everyone else was in between.
Okay so here's the model I have. When I went into that office there, I go, you know what you could dump lets say United Concordia. It's only ten percent of your patient base but your discounts are at four points off your top line, and if you can otherwise keep busy and keep most those patients, if you do those things the way you can. You can add, two- three points to your bottom line, but first, before you get in a fight, call and negotiate. The lady goes, "I'm a tough negotiator, I already tried." I said well, they don't negotiate sometimes, until you throw down. Tell them you're going to drop. She said, "I'm going to drop." The next day they had a suit from her insurance company, and they gave her a big raise, so then we went on to the next PPO. Here's my thing, there's always PPO negotiators, but if you don't have a credible threat of a drop, you can't do anything. Union can't strike, you don't have any muscle. The has to know that the Doctor, the person on the phone calling says, can pull the trigger, and I'm out of there. Then sometimes they'll deal you even when they say they won't.
I walked into the next PPO and I said that's fifteen percent of your patient base, and if you lose the whole fifteen percent of your patient base tomorrow, that would be bad, but if you lose, if there's maybe five percent, a third percent of them at risk. Hard to explain everything, if you lose five percent of your patient base, over two years, you can heal up over that, but you've added to your bottom line, several points of collections. Rather than going to how much do I save on percentage point on supplies or something like that. These PPO plays are huge, but it's a matter to bring this full circle, of having the right mix. Not too little, not too many. It's sort of a clunky form of[inaudible 00:10:12] now days. Like a gas station, turn the pricing up or down, it's a matter of bailing out or adding PPO's so you're at about the right level of buoyancy.
Howard: What is the end result for most of these dentists? Your going to try to get rid of the patients on their PPO plans where they're losing money?
Bill: No, it's to lose the discounts, and keep the patients. Most people that go through the process of where I tell them. If the indicators are, I never, most of my clients all are the long term. I don't want them to get hurt, anymore than you guys want to hurt patients. I wouldn't be recommending stuff if I thought it was going to hurt clients, and I have longitudinal studies, because I have clients that have been through these transitions, and on both sides of whatever participation. I can see how they do, and I have learned. The point on this, is you don't lose the patients if you handle things right, but I would never, recommend a client get in a fight they couldn't be okay with. In other words, I've been in enough fights, that you don't' drop PPO's Willie-nilly. Always negotiate first, and maybe you drop one, how's my balance, how am I doing?
Howard: That is one of the corporate dentistry's, when they buy practices, that's their secret weapon. They can usually buy a practice and by renegotiating the PPO's, they can almost pay for the practice over five years.
Bill: See, this is what pisses me off. When you buy a practice matching up the PPO's nowadays, is really important. Especially, you know I have a client every other week doing a practice merger. You've got to be aware of which PPO's you're on and they're on to see if they match up, and how you do the deal. That's the one thing that pisses me off about Harland, and others. It's fine that they can get together and do a buying club because individual bands just can't.
They can do a buying club through the Manlde brothers or Woody or whoever else and that's fine, but if you get together with your Seattle study club, and want to negotiate fees, that's coorusion, if they have four hundred practices, they can bargain. To me that's an unfair competitive advantage, and it should be stopped. If I was in the ADA thing, and I'm not, I would say if there's one thing I can ask it's that the dentists can collectively bargain because there's this thing in economics, where big business reads big raver because they have to balance it out. If you have just pone seller or just one buyer, there's too much asymmetric in that marketplace. It isn't fair.
Howard: That is very well said, very well succinct, and you know what, if you talk to them, they'll do it. I remember when I got out of school there were four things. I went down to the ADA with Gordan Christian, I think our issues were, take a stance against managed care, and national advertising and what was the third and fourth. Anyway, they're lawyer met with us, they all met with us, and they listened, and over the next few years, they did basically everything we asked them to. They've got like two hundred employees, with a lot of departments. They've got legal, I guarantee you, if you talk to, I don't know if Sphinctus is the same guy running it, he was there for decades whenever I dealt with thing, but if you explain this to the legal department, they'll ...
Bill: I can't believe someone hasn't already but okay. I mean I'm not a doctor, so I don't know.
Howard: Yeah but you have slept in a Holiday Inn Express, and you have a bald head. You know, if you have a bald head. You know if you have a bald head in dentistry, you're already a legend.
Bill: Before we go further, I've got to show you through this. Can you see this?
Howard: Oh my gosh, lift it up higher, oh my God. Who's that?
Bill: Proof that you once owned a suit.
Howard: I don't even have that still.
Bill: This is from your dental mania seminar. I saw this in a clients office and I thought man I remember when Howard use to wear suits. Right now, thinking of you is like having a bald eagle in a bikini. It's just too obscene and weird to think about.
Howard: Would you take a picture of that and text it to me or post it?
Bill: You don't have this? Look at how good you look.
Howard: I don't even have that. Oh my God, that is hilarious. When you, your big deal is that you're always coaching dentists to watch for statistics, and you have four ways to make the move. They are production, collection, exams and production per exam. Could you go through those four? Why are those the four most important statistics for you, why do you focus on them? Go through each one and let our viewers know what they should think about those four.
Bill: Okay. I'm going to give you this. I'll give you practice management one-oh-one, right. The purpose of the dental office is to deliver care. We manage how much care we deliver by production because the common denominator of all the procedures, is dollars. That way you can say, if productions is up you can put the increases aside. Assume their care is up, versus saying how many of everything we do every month, you never get thought a deal, so production is just shorthand for care delivery.
If you want to grow, you have to produce more. To do that, you either have to see more people which are measured by exams, periodic, limited and comprehensive because that's the best way to measure volume in a patient, everything in a practice, everything comes to that. In the Target store across the street from my office, they measure how many people go through the cash registers. That's sort of the marker, now Charles Blair uses trophies. Adult, child and half the forty nine tenth, I like to use exams. You either have to see more people, exams or do more for the people you see.
Production per exam. Production per exam is a function of services kept in house and endo, perial, implants, and so on. Also and most importantly, patient compliance, or conformance. That's my hierarchy of steps, when I go into a practice, I look at that. You either have to do more per person, see more people, and if you do either of those two, you have to get more done per day, unless you are working more days. If I look at it that way, great. Collections you look at because if there's a huge gap between production and collection, it's in the office, that PPO thing we talked about. It's not unusual for me to see doctors that are collecting seventy-five, seventy percent now which is crazy. My client base right now, the average collection percentage is eighty five percent.
If I went back in time, to when we both had hair, and told you that in the future, my clients will average a collection of eighty five percent, I would have accused myself of major malpractice in the future, but the typical doctor up here is working a couple months of the year for free for Delta and others. That's my hierarchy of points. That's how I break it down.
Howard: A lot of people, I want to know, of your two hundred and fifty practices, do you see common denominators? Are the ones doing better, have certain technologies like these are big decisions. They come out of school two hundred and fifty thousand dollars in debt, then they see these hundred and fifty thousand dollar cad cams, they see hundred thousand dollar CBC's, they see seventy thousand dollar lasers. Are those competitive advantages, or do you not see that to be correlated.
Bill: The biggest competitive advantage, is a well located office, with a big sign. Which you've been preaching since the day you started. It's such a huge difference, it makes all those other things, seem small. I've never been able to prove, for example, that new patients went out because of SARAC. You see advertisements, we do SARAC, I mean what the heck would a patient know what that is? As a matter of fact, one of my clients you know Scranny. Mike Scram stead and you know Sara Agai. Even he, I don't think would say it's the cure for the common cold, and new patients and practice, everything.
Howard: You know what's weird is, well granted, I had two patients this week that wanted the same day crown, they specifically wanted that.
Bill: They want it, I just don't know that it's a huge factor.
Howard: In my office, I ask every person, if you or I came in, and I said, you know what Bill, here's the deal, I can do it all today, but you're going to be in this chair for two and a half hours, or we can do it the conventional way, and it well be an hour today, and you'll come back, then you'll come back in two weeks, for thirty minutes. In my office, four out of five people, just take the hour, and I'm going to come back. Four out of five.
Bill: That gives you the same day dentistry angle, which is all the rage now. There's a lot of advantages to it but if you're talking about overall success, the Combine, the SARAC, doesn't really do it. You know, I can put on a graph, higher technology, new patients and stuff like that. I can put on a graph ...
Howard: Let me ask you a different question, some people believe that, it's really high over head's related, because you're just doing cleanings, exams, fillings. The high margin stuff, a crown, a molar root canal, placing an implant, a denture, a partial. Are you more likely to have more net income, if you do molar, endo, place implants, do dentures, partials. You know the bigger thousand dollar procedures, that probably have fifty percent ...
Bill: The people that I have that net the most, my average clients probably net three fifty to four hundred, in that area. For the people that net most, because they have the most patients, so they have a lot of hygiene and hygiene is not as profitable as doing endo, but it chugs it chugs, it chugs. You put the endo, and the implants and all that stuff, as icing on the cake. I do have a few boutiqey type clients, that do well on margin, and the profit margins look better, and that sort of thing. You ask me who the wealthiest dentist, they are the busiest dentist, with the most patients.
Howard: When you say a good location office with a big sign, which I am on the corner of forty eighth and Ida. I paid two hundred and seventy five thousand dollars for my lot in the grocery store, that was back in eighty-seven. Do you see any better demographics on the dentists that went rural verses urban?
Bill: Yeah, definitely here's the thing, just like you've talked about a million times, in our state, there's like five really tough places to practice, Udina, where I am now, Wisetta, Woodberry, North Oaks, and I think Still Water, and these are all, high income, too many dentists, looking for too good dolls and too little Frank Decay. If you go far out to Ordenville Minnesota, Ordenville Minnesota, I call infinity because where the parallel highways of fifty five and twelve merge, and they say one definition of infinity is where two parallel lines meet, they meet in Ordenville, okay. If you go out there, you'll have lots of patients, they don't have much money, low down I Q's lots of AMA, lot's of write offs that sort of thing. Now the sweet zone ...
Howard: Lot's of MA?
Bill: Lot's of medical assistance, low income stuff. Now you can keep busy there, but that's not the sweet zone. The sweet zone is to be living about one hour away from a sushi bar, about one hour west of here, where you have this combination of decent income and stuff, not too many dentist so the exurb is going to be one one hour west of here, is a sweet zone, and those doctors are just killing it. They still sometimes have a hard time getting associates, but if you go out to farther west Minnesota, you could keep very busy and have your own airport, and a city cab, and if you want to do well. What happens is, until they graduate female dentists, who have grown up in the country, they're not going to get a lot of dental staff, it's politically incorrect to say, but half the dentists are female, they tend to gravitate where their family is. If their not from a small town, it's not going back to a small town.
Howard: I've always said that the dentists wake up in the morning and they commute an hour into worse, and worse, and worse demographics, and if they would have got up in the morning and headed the other way, out of town, they would find a place where they're actually needed. Dentistry comes down to supply and demand, and franchises always have the best demographics, and dentists don't even look at demographics.
Bill: Yeah, well they are increasingly. My clients, whenever they move, I say, don't you dare put an office where you won't put a Starbucks. You have to put a sign up so you don't have to sign up. I have clients that are real successful in professional buildings and stuff, and part of that is merging practices because you have this kind of thing that works out, if your in a mature area with lots of dentists and professional buildings, they're retiring now, so you consolidate practices. There's always a way, but your right, why do they keep fighting over the same thing, if you gave me all your skills and a [inaudible 00:22:41] and a suite full of equipment, and say just private practice in the medical arts building downtown, Minneapolis, I'd say, just shoot me. I don't want to start a practice down there.
Howard: These dentists should be looking at your local state journals, and on dental town in the classified ads, by the way the classifieds ads on Dental Town, is one of the most overlooked jewels in there, I mean the highly active. They should be looking at practices for sale and their zip code for mergers and acquisitions. What should they be looking for?
Bill: The classic great deal is some dentist that's retired that was just sort of house flying for the last ten years, his equipment not worth anything, his lease is up. He sells the practice. He has a decent relationship with the lease and looking at the location and saying yeah this guy is okay. He sells the practice, and you basically throw away the equipment, and take the patients. That's your pretty one. Those things work so magnificently.
Howard: What would be the metrics on that? Would you pay, how much would this dentist be doing a year, and is that related to the sale price?
Bill: Now we go to the exams, and production for exams, so lets say you have a dentist with a practice that's all run down. Instead of doing like a hundred and thirty a hundred and fifty exams a month, which most doctors do. Let's say he's doing fifty, but he's doing not five hundred dollars per exam which most doctors do around here, he's doing three hundred, right? It's just, really?
Howard: These are new patient exams?
Bill: Total exams, so I look at his total exams and go hey you know what, if you buy this doctors practice, all things being equal, you'd do two hundred dollars more per patient, than he does, plus you get a fresh look. Most of you have the patients go out the back door, you've got amnesia if they came in the front. You'd see a lot of stuff you missed, because your house clients are your patients, so you get a fresh look, but your also more monic, because most older guys, I'm stereo typing, there's always exceptions. Most older guys though, coast in last private practice, they're in close, so they leave a lot of dentistry undone. You go in and let's say thirty of those patients actually stick, the other twenty won't drive fifteen miles to get to you or something like that, but your doing ... Let me get my calculator, say your doing I don't know, ten thousand dollars on that and you might have paid for that kind of practice, oh I don't know, let's see, you might have paid for that practice, you know a hundred and twenty hundred and thirty thousand dollars.
Howard: How did you get a hundred twenty thousand dollars, how did you come up with it?
Bill: I was just using a crude rule of two hundred dollars a record, that kind of thing.
Howard: Two hundred dollars a record.
Bill: I've seen them go for five hundred a record, because if you look at advertisement costs about three hundred dollars a patient to get the phone to work.
Howard: If your new patient acquisition cost is three hundred dollars a new patient, then you can, merger and acquisition, if you can buy a practice for two hundred and fifty dollars a patient would be a hell of a deal.
Bill: It's much more predictable too, and there's more dentistry to do because you know the lay of the land. How you handle the merger is important, the PPO issue and all that other stuff, but it's the best deal in dentistry, and everyone knows that. That's why Midwest now buys the practice, so look at this, this is what you're looking for. This is my January two thousand web in Bolton. Let's say Midwest Dental or someone buys the practice, that's collecting a hundred thousand a month, the net on that is typically thirty five thousand, right.
The dentist typically, is doing two thirds the production, sixty six, so now he's not an owner, he's a worker. You pay the dentist about a third of that with some adjustments. The dentist makes twenty, so the certified net income is assuming the practice is still rolling. Even if you don't get economies to scale and other things. You pay the dentist twenty, you got fifteen thousand a month profit. Debt service on a [inaudible 00:26:32] like that is like ten thousand. Your paying the bank one hundred twenty thousand a year and you get one hundred eighty thousand back. Do that in the bond market.
Howard: Bill, you have an online course on Dental Town that we love, you never made a post. Can you post your newsletter? Can you start a thread, and post all your past newsletters that are still relevant.
Bill: I count if they're posted their, they're copywriter or something that you can't do it and have it. The context.
Howard: What's that?
Bill: If I post my newsletter does it mean I'm giving up the copy right to my own ...
Howard: No
Bill: Okay.
Howard: I'm not a lawyer, but no, I don't believe that at all. On every issue like that, we've worked with a law firm since day one, so when they sign those terms and agreements there where most people just click yes, but yeah your protected.
Bill: I'm protected because I know you , mostly. I'm going to ask Kelly to look at that and maybe we can post the last couple years bulletins, because I'm kind of proud of them, they're serious economic indicators and advice, and everything I have to do, I have to keep it real. I'm not trying to make everything a million dollar practice. I'm trying to make most doctors, normal doctors, happy, and busy, and organised.
Howard: You are the real deal. I mean I can vouch for that any day of the week, but when you just said you're not trying to make them a million dollar practice, but you said you're clients are averaging a three hundred and fifty thousand dollar net. First describe what is-
Bill: They're not asking over a million. My typical, if you broker it all per doctor, my doctors including the hygiene, that's related are somewhere between a hundred and ten, hundred and thirty thousand a month.
Howard: First tell us what is the average office, according to national statistics, the ADA.
Bill: I look at an overhead service here that comes from an office called KDB. It surveys mature practices, so you're leaving out starting practices and retiring which can skew the averages. The doctor average creases about seventy five, eighty. Flex about sixty five, something that way, nets about two hundred and eighty, with a thirty five percent net, something like that.
Howard: What would the American Dental Association say the average is, factoring in everybody.
Bill: I use to look at those statistics but I don't weigh into those because I have better statistics for my area in this, and that's what I use. Plus my own database, so if I was at the office here, I would show you I have this huge screen, in my office, and I point this to it and you see all this data because I monitor thirty one million dollars worth of dental production a month running through my office. I look at the screen, and it's just like, here's the dashboard of what's real.
Howard: You are one of the most positioned people, You should start a corporate chain. You would be able to manage that better than anyone.
Bill: I kind of like the idea of the dentist making the final decision. My uncles a dentist in [inaudible 00:29:18]. I really am comfortable, the idea of a corporate chain is there's always going to be some mylogeniation. The whole beauty of it for me is to go into each practice and make it more of what that doctor wants that fits his personality. It's like you don't mow down the landscape wherever you go and install the same golf course. You go, this has a really good set of sand traps, lets leave those alone, and work with it. I see my job as helping the doctors, at least keep with professional management so that they are strong in the face of corporate dentistry. I don't really want to be a suit, and I want the dentist to make the last decision.
Howard: First of all, the continuing care, ten point check list. Do you go through those ten points? Do you commit those to memory, or is there something more productive that you could talk about.
Bill: I do them from memory, but you know what I want to go to here if I can switch it up a little. What I wanted to go to was the management by fear article that I wrote for you and something called the ferrin report about umpteen years ago, and then Pablo Venice did it because it fits better
Howard: Your going to repost that on that threat you're going to start. It's going to be you're first post. It's your virgin post.
Bill: I've posted twenty times there. It's just that I'm in a meeting or I'm racing between a meeting, or working out, or watching TV and having a beer. I have to tell you, I love these podcasts, because for an hour I can go for a walk or something and listen to it. I think it's really a cool thing your doing, I've listened to a bunch of them I really enjoy it. One of my favorite sayings, since your semi Buddhist, I think you relate to this, is there's many mountains to heaven and many paths on each mountain. I just listened to, younger guy that I'm sorry, Costos
Howard: Mark Costos.
Bill: There's always different ways to do things that are pretty cool. The thing I wanted to go to was management by fear. That was the article. Everyone knows that it's important, and it's probably off the outline, I don't know. Everyone knows it's important to be hardworking, smart, have integrity. You know and that sort of thing, as opposed to being lazy, dumb, and sleazy. One of things that's left off is courage, and what happens is you know what you talked about that in your deal with implants, where doctors don't really get into implants. Well that's a clinical thing, I can't really speak to it but doctors wont join a PPO in that because they want to get busier and make more money, it's because they're afraid of losing patients, or they will not fire a bad front desk person because of fear of that, or they will not add a new room because of fear of cost, or they want to add hygiene time.
My whole thing of management is you've got to focus on maximizing opportunities verses trying to avoid loss, so Peter Druckers deal is costs are inevitable in business, what your looking for is result control. For example, I want to talk about the hygiene thing. A doctor isn't growing, and he asks me to come out there, and I go, "Why am I here?" I'm not growing, I love my practice, but it kind of seems like I'm stagnating, and I don't know what to do, and I go, "When's the last time you had hygiene time?" "Well I'm not going to add hygiene time, I'm not growing." I go, "Right." He goes, "Well I already have open time in hygiene." As long as your scheduling humans, and if you wait for open time in hygiene to get to zero, you're never going to add hygiene time, and you're never going to grow.
Take the big risk, I mean jeez you bought the practice, or started it. What's the big risk in adding another day of hygiene, and then you'll see someone build a brand new facility, and it's like Doc, you built the queen Mary, put a sailor on it, you know. That's the angle I kind of wanted to take with you, because there's so many opportunities, like adding another room and the cost benefit for a forty thousand dollar room. I just dealt with this last week with a client. You know what the cost went up it is. You have to use it about ten times a month, and you're making twenty percent on that room
Howard: Why don't you send me that article for Dental Time magazine. I've been screaming that forever. I mean every single hospital, has an emergency room, and then they call the front desk and say, "Yeah I broke my tooth." She's looking at the schedule, she doesn't have a room, so she goes, "Well what about coming in tomorrow, or the next day? They make the appointment, and then they just hang up the phone and they call someone else. This is America, they're just going to keep Googling dentists, until they find someone that will see them. Why can't you just have an emergency room? You should add opperatories, until there's an operatory that went the entire day, without being used. They don't get it.
Bill: The cross benefit, when you crunch the numbers, the payoff is insanely big, to do them. I was just in Rochester, in the practice there. They're looking at a six hundred thousand dollar expansion, plus a hundred thousand dollars worth of equipment, and we lay on the numbers. They would have to do forty thousand more a month there, they just hired a new associate, that's his wing, it's fine. They're going to make about twenty percent profit on that. The margin will go from there. You go well, they could save a bunch of money by not doing that Bill, and it's risky to do it but they have the balls to do it, or the ovaries or whatever.
Howard: They're living in fear, they're not going for it?
Bill: Well these guys aren't living in fear but there's a lot of doctors, if you practice with the same optimism and courage as when you first opened your practice, what happens is we get older, we have more, and we're afraid of losing it, and then you clench up and you don't keep stretching. Either on continuing ed or procedures you do, or adding rooms, or doing these things, and a lot of times people, "I'll just work harder, I'll just work harder." I'll just get my crown margins better, and what they really need to do is ...Dentists have plenty of courage. They have to find the courage again, and take a little bit of courage, like in dropping a PPO makes up for a lot of work.
Howard: Look at the turnover even among the most elite players in the fortune five hundred. I mean go back every ten years. What percent every ten years, fall out of the fortune five hundred?
Bill: I don't know.
Howard: I can only think of one, that was there in nineteen hundred that's still there in two thousand, that's General Electric. I can't think of a single-
Bill: They get to coasting and then, yeah.
Howard: I was stunned that Apple, lost so much market share, because they didn't bet on the six plus phone, when Samsung did. They decided to keep one, that same small size, and Samsung said, "Shit, we're going for it." I mean I had so many iPhone fanatic dentists, that actually switched to Samsung for that bigger damn phone. Even Apple was afraid.
Bill: You get to a point where you worry more about losing something, then gaining something, and then you clench up, and don't grow. A lot of times, it's kind of a cliche, but it's sort of true, practice growth is a reflection of personal growth. I'm Mr. Tactition and stuff but I'll say to a doctor, come on you can take a risk like this. I would not suggest something if I didn't think it was pretty good odds of it working out for someone.
Howard: My goal is to guess the questions of our listeners. I'm trying to sit here and guess what seven thousand people are making of what you're saying, and I already know what a lot of ... I'm fifty two, how old are you?
Bill: I'm sixty two.
Howard: Are you really? Damn, you look better than I do. You are amazing, no I'm serious dude, you absolutely look younger than I do. I think I've had fifty two Sammy Davis Junior years. You must have led the good life.
Bill: I just keep your picture on my wall, and I try to emulate you in that suit.
Howard: So many of those dentists, and I went through the pain, I went down to [inaudible 00:36:57] for five [inaudible 00:37:00], so you're saying do more exams, and they're saying do less. A common pain key deal is you only need fifteen new patients a month because if you did a complete exam, and you did it right and thorough, and presented it right, you only need fifteen new patients, and they say things like, I wouldn't even know what to do with fifteen new patients. What do you say to that dentist, listening to this who's [inaudible 00:37:21] he's thinking, "I should be doing less exams, more complete exams, more thorough exams, and this Rossi guy's saying do more exams."
Bill: My mantra to my team, Howard, is our job is to help our clients, not reform them. If the Doctor set on being a pink Dawson dentist, we'll help him with that. If you're asking me in general, we don't try to twist things around. If you ask me in general, I think it's a dying model, not because of the clinical excellence, I mean again my uncle was a hanky guy, and all that. It's just that this idea of an hour and a half new patient exam. Remember you use to talk about practicism verses consumerism, hank is the epitome of practicism. Now I'll probably get hat email for that, I mean I have a lot of respect our clients see that. It is an excellent model, but it's based on what the dentist wants, not what the consumer wants, so again, a matter of balance. You can go all the way the other way and sign up with every PPO, and be open seven days a week a stuff, and maybe you don't have enough balance in your life. Then let's pull a little batch here, what's the balance you want?
Howard: I want to ask you another question. When you ask a dentist, and you say, "You know, is this just all about you, do you just look in the mirror everyday, and say, it's all about me, or are you focused on the patient? Are you patient focused, or dentist focused." A hundred percent say, "In my office, I'm patient focused." I say, "What are your hours." They say "Eight to five, Monday through Thursday." "Are you open any evenings, weekends, Saturdays?" "No." Just as that, hours, you have a lot of clients, you've got two hundred and fifty, do hours, are hours a game changer of competitive advantage, or not really?
Bill: They do, but there's a tighter correlation from as far as I can see, in the total hours you're open per, than what hours you're open. I can't prove that Tuesdays evenings, for example, are better than Tuesday mornings but I know that if you have more hours during the week, you see more patients.
Howard: There's a hundred and sixty eight hours in a week. How many hours should this facility be used? Again, since I'm not the doctors boss, I can't tell them that but I can say this. That for example, it's crazy not to have the phones covered on Friday, and if you're a new associate, you better be okay with doing hygiene. If I was a new doctor in a practice, and wanting to get some traction, I would be around Friday afternoons, and I'd learn how to do endo. At least get it started, so Friday afternoons half the dentists are out, and two thirds the dentists around here are closed. I definitely, if I was starting would go for Saturdays, and Friday afternoons, something like that, because it definitely gives you a competitive advantage. Again, I'm not the boss, I can't say, "Thanks for hiring me, now you work Saturdays."
Bill: Okay but a lot of people say a lot of things, that they just want to believe. They just want to believe it, so they say it, and if you say it enough times it's true. No ones ever going to up on Saturday, everyone who's ever tried to stay open Saturday, no one showed up.
Howard: Despite all that, everyone says that. I have not been able to prove that offices that have Saturdays, or Friday afternoons, or evening hours, have more cancellations. I think that's a myth.
Bill: Do you think that dental offices open early morning, evenings, Fridays, and Saturdays, on average, are more thriving, growing businesses, than the ones that have-
Howard: You have more hours per week. It just stands to reason, if your restaurant, opens six days a week, if you open seven days a week, you'll have more business. If your office is open more hours, you're available to consume more hours, and if your in a [inaudible 00:40:44] like [inaudible 00:40:45] Minnesota or something in that[inaudible 00:40:46] you want to work until seven o'clock a couple hours a week, if your trying to build a practice. If you're fat and happy, you don't need to. Yes, I would work those edges but again, I can't command them to do it.
Bill: By the way, to you dentists out there that said they can't find an associate, I mean come one, the navy finds them, to go send an aircraft carrier, for six months, while their wife is back home. They can find an associate to give up sex, for half the year at a time, to go on an aircraft carrier, and you can't find one in Salina Kansas, that's just a bad attitude. I know associates, that came out of these dental schools, that left Phoenix Arizona and went to very small, rural towns in Iowa, and Kansas, and Nebraska, North Dakota, or signed up in the military, and most these dentist that can't find an associate, I say they all have one thing in common, they didn't even try. You know what I mean? They didn't, they didn't even try. Fife thousand kids, came out of dental school, last may, and you can't find an associate? I'm three quarters done with the man. What would be the best return on investment for us to talk about these last fifteen minutes, the last quarter. We're in the fourth quarter of this football game.
Howard: Well, I was thinking of doing a couple more cross benefit things, but I think we'll leave that. Let me think for a second here. I'm going to go over to the case presentation thing. I listened to the stuff you had with Blanchard, and I just Bill Landford and others. That's where we have a Dental Town, see and it's one of the things I'm most proud of. It kind of ties into this, and I know we're off outline Howard, so thanks for putting up with this. Here's the deal, I work with dentists for all kinds of different things. I do have Hanky Dawson type guys, and I have people the do LDI, and all kinds of different, clinical protocols, and religions, whatever you call them, and then I work with doctors that have multiple doctors, and hygienists in the practice.
One of the things I was really bugged about early on, was this thing that your carnal bridge percentage should be thirty three percent or something. That really bothered me, and it bothered my clients too, because I'm sitting down with a doctor saying, "Your carnal bridge should be thirty-three percent." Where the hell did that come from? Well it should be thirty three. Well I do all my carnal bridge and I get in these insane arguments with the doctors, and they will get defensive about, well I'm doing all the carnal bridge I should, and stuff. I go, how to I reconcile this?
I was in this one practice, when I was first starting, well I had more than once, and I'd be sitting in the practice, and the hygienists are all arms folded, and their all negative. I go, "Why are you guys giving me so much attitude?" And they said, "Well the consultant before came through here, and all they did was do this." I go, "What do you mean, all he did was do this?" They said, "All he did was just fire up the panels." They saw that the consultants job was to push panels for profits, and I go God, I'd never want to be that guy. I never want to think in terms of quotas for healthcare, to me it's just the opposite of that, so you switch each criteria.
What I do, is when I get into the practice, I have people get in touch with an enbeli system. When they clinically calibrate, for example, most doctors have had meetings in the last year in HIPPA, OSHA, when's the staff party going to be, collections or something, but they haven't had one meeting where they sat down and said, "What do we believe in? When do we crown a tooth, when don't we? When do we do an implant? When do we do endo and try to save the tooth? What types of crowns do we use here? When do we use metal, and when do we use composite, if they do both?" They never even go through that, so whenever I take them through that, say for example, what are your criteria of the common tooth? Everyone all the hygienists, the assistants there, think of all the conditions, that would require crowning a tooth.
They sit down around and go okay, large filling. Well how large? More than half the esimes. Well okay. They go through all the things. I have them all list their things, and they boil it down, and then I say, "Okay would you say all the people with large fillings, root canals all these things, already have their crowns?" They go, "Well no, not even close." Based on your own value systems of pawning off variability yeah, so now we're not talking quota, we're talking criteria. When people meet that criteria, are you recommending these services? No, we're trying to analyze their lifestyle and other things like this. I say, stop being a dental authority, be a dental advisor, and what you lose in authority, you gain in authenticity. They get great case acceptance, the doctors aren't unhappy to see me and my team because we're not trying to take them against the grain. The hygienists and everyone realize that we're trying to help people because they actually like their patients.
Bill: You have so many consultants that you know, thirty three percent of you patients, should be in a periodontal disease, office management. What if he looks at your position and you say I'm sorry, eight percent of my, patients have an STD, so we're just going to treat you for clamidia. I mean really?
Howard: My sister Sharon shows up at the Obgyn, we've got to get twenty D and C's a month, as opposed to thirty, we've done nineteen, you need ... I just hate that. Of course hygienists, and everyone else hate that. You go, okay, I'm not going to do this, but have you been really presenting things based on your criteria? Now the real ride on these conversations, is when the doctor and staff talk it over, they're really testing their own convictions. Here's my siliagism on it, as you clarify your thinking about what you feel is best for patients, in actual clinical discussions, with your values, honestly displayed. Your language clarifies, as you clarify your language, people understand better. As they understand better, they make better decisions. As they make better decisions, you can do better stuff. As you do better stuff, you get better outcomes. If you look at that whole chain of events, you clarify your thinking, better outcomes for patients.
Bill: You started off this hour, saying your two big national mentors are about PPO exorcisms you called it. Rossi's got to be Italian or Italian, so I assume you were raised catholic?
Howard: No, I wasn't I was Methodist, and Mormon Italian. By the way, do you know the three best years in an Italians life?
Bill: What?
Howard: First grade. Don't get mad at me out there.
Bill: The best dinner I ever at was with my son, Eric, in Venice. I lectured out in Venice, and he went with me, and I mean we went to an Italian restaurant there. I mean, once you eat Italian food in Venice, you realize, they don't even have Italian food in the United states.
Howard: No.
Bill: People just don't get it. If you go to Mexico City, and order anything that you order, in America at a Mexican restaurant, they just look at you like, crazed, like, what are you talking about.
Howard: I was in bail, or Le chi in Italy, and we saw and Italian group try to do a gospel song. They didn't get that either, so there's some things we can do and there's some things they can do .
Bill: I ate this about three hundred dollar meal in Venice. I mean, it was this huge meal, and a bottle and all nine yards, and I got it for free because right when I was done and getting ready to leave, this man two tables over, who had to be seventy five and senile, looks over at me and goes, "Are you an American?" I'm like, "Yes." He just starts tearing me a new one because I'm an American, you know. The owner just got up , and he's all embarrassed, and he throws the guy out of the deal, and then he comped my dinner, and he said he was so sorry. I thought, man, that was awesome, I wish someone would yell at me at every meal. Go back, I've only got you for twelve more minutes, explain why that clinical calibration. Now you were talking about that within your office, is that what you were explaining? Is that part of your clinical calibration?
Howard: On a continuing ed things that I have on Dental Town.
Bill: Give them the name of your course, and explain the course.
Howard: I think it's called, well I think in terms of clinical calibration but they search my name and it's something like that. It's setting clinical protocols. I think I'm kind of the guy to investigate. I remember hearing Rick Wirkwin, he's talking about, he has everyone sit down and write things. I've been talking about this from, since nineteen eighty or something, because of the conflict I had about losing percentages. It works so well, so we don't have to have lots of consults or any high pressure at all. We just do code diagnoses, and we have a bunch of real simple ... Everything I have to do has to be user friendly, otherwise doctors wouldn't actually do it. I actually, I would have burned through my market place, a long time ago you know. If I don't keep clients happy, I don't have them.
Bill: Well walk these young kids because the young kids five years out of dental school are devouring these podcasts. I mean, they're from everywhere. Walk me back through the day, remember when we were young when readers digest took study models and x-rays to thirty different dentists, and how many treatment plans did they get?
Howard: I've heard of that.
Bill: They got thirty different treatment plans.
Howard: Yes.
Bill: All the dentist are like, "Oh Readers Digest is so horrible, this is just horrible for them." Dude, your mom has Readers Digest on her nightstand, and it's grade A journalism. I mean the bottom line is, you can't say dentistry is a science, because if you sent a person for twenty new patient exams, in your city, in your zip code, they would all come back with different treatment plans.
Howard: That's right, and I have dentists, that I trust with the lives of my kids, that are a completely different spectrum. The important thing is that their true to their own inner laws, right. That's that many mountains to heaven and many paths on each mountain. I'd say to the young guy, you want to find a practice, where someone actually has discussions about this so you can sometimes agree to disagree, but your coming from an ethical standpoint about what's really best for patients. Then if you keep up with the science the case in section states scare them selves.
The production, per exam goes up, without, for example, no statistic I do not track, and again if others want to track it, great. I don't track the acceptance percentage, because it begs the question, what are you presenting. If a dentist says to me, "I get a hundred percent acceptance." I think they'd they're either blind or crazy because they're not properly examined. I don't go by the acceptance percentage because I don't want the staff to feel pressured because if they feel pressured the patient will feel it. Basically, consults will treat you like the way they want to treat the patient.
They're kind of canned and high pressure, they want you to be canned and high pressure. Where was I? I don't want them to feel that pressure, if they're getting results, the production per exam will go up. That's the proof, if your recall system is getting better, there's one statistic that proves it. Your PAR exams are going up. That means more people returning more regularly. If it's not going up, it hasn't improved.
Bill: Do you see anymore success in treatment plan acceptance if the dentist doesn't do it and a lot of offices have a treatment plan coordinator.
Howard: Not many offices. I mean orthodontic office have it.
Bill: Why do ninety percent of orthodontists have one, and ninety percent of general dentists do not?
Howard: Boy, I wish you could tell me. Here's the thing, I think probably less than three percent of GP's offices have them, and when they have them it's just fabulous. You know what, you can hire a hygienist, you park them and you know what they're suppose to do . You hire an assistant, you know what they're suppose to do. You hire them at the front desk, you don't know what they're suppose to do but you don't see them not do it or whatever. They're there. Treatment coordinator is like, jeez, I don't know, it hasn't formed.
I go, my God, the real purpose of the treatment coordinator is just to hold, like I had three boys go through ortho, hi I'm doctor, so and so and you sit down with Mary Jane, and she says, "Well your kids teeth are crooked." Indeed, they are, yeah and that we'll be five thousand dollars. Okay, let me think about this, do I love my kids, yes, and you said the teeth were crooked right? Yeah, and it's five thousand dollars, yes, and the teeth are crooked, and I love them, yes, so all the treatment coordinator is doing, is sitting with you on that, so you can cycle through this. Dental will say, you need a crown someday, or we should do that, and you bounce off the front desk ,they go well they want to do it now run a predetermination I know haven't , see you later.
Whereas if you sit down with someone, and say, how do you feel about what the doctor told you? wEll I'm kind of in shock. Well I'd be in shock too. You weren't expecting a thousand dollar type deal were you? No. God I just don't know, and you just hold their hand. I really believe in treatment coordinators, but they're rare as hens feet. That's one of the next evolutions of practice, practices that have treatment coordinators are truly elite.
Bill: They're amazing, and if anybody's listening to this that knows one that wants to do a podcast. If you're a dentist, you have this and you want to have me podcast it and be heard. I mean, they're rock stars because they're getting them to sign the dotted line, and they're collecting the money and they're closing the deal.
Howard: Yeah but you know what, it's also just humane. I mean you don't shock someone send them out and okay we want to do this. You're giving people time to cycle, Sandy roth talked about this years ago. I loved it. You remember Sandy Roth?
Bill: Absolutely. She's be a great podcast. Don't you think she'd be a great podcast?
Howard: If she's still working.
Bill: She wouldn't have to be working, she was a goddess for decades.
Howard: I know, I saw a seminar of hers down at Woody's and she did this cool thing, and I use it all the time. I'm happy to steal from everyone, but at least I've got the acknowledgment of it. She says, when you tell someone someone, they got through the stages of grief, shock and denial, this can't be, no one in my families and gum disease, anger, this tooth was fine until you touched it. Denial, hey can't I do something, someone. Then they go through depression, then they go through acceptance. I tell my front desk people, when they come up front, to ask the patient, how do you feel about the doctors recommended, and they go well I'm kind of bummed out and they go, great you're almost to acceptance. At least at the bummer stage, you're not in denial. Well the service of the treatment coordinator is to sit with someone long enough so that they can cycle though the emotional acceptance stages, which are real.
Bill: Absolutely. I believe that one of the accesses tendons of dentistry is that, you know my assistant, Jan has been with me since day one, twenty eight years, she went to nine months school to become a dental assistant, the hygienist went to four years of college. I went to dental school and then they hire a receptionist off the street and there's no receptionist schools. They're the least educated, they're the least employed that we've invested in.
Howard: They're the least specialized, I would say.
Bill: The least specialized, how do you recommend getting front office ramped up and specialized.
Howard: For treatment coordinators, if we're still on that, the best treatment coordinators are an assistant or sometimes a hygienist, that can't do hygiene as much because of hygiene or something. Not all assistance are bent that way you know, some assistance just are very non confrontational. This can seem confrontational but again we try to take confrontation out. Hey they're a train going by.
Bill: I know, I love it, I love it. I live right off I-ten, and people don't realize that I-ten from Los Angeles because Los Angeles, Phoenix, Tucson, El Paso, Houston, New Orleans, all the way to Florida. It's the most busiest rail line there is because your options are, I'm either going to sail down two weeks on the Panama Canal pay one hundred and fifty thousand dollars to cross, and sail two weeks back up, or I'm going to unload it all on the railroad on I-ten and ship it to the other site, so when I go mountain climbing in Arizona, you always non-stop are seeing these trains that are like a mile long, double decker.
I got probably the worst beating of my life when I was ten, and I was with my little sister Kaylene, and I talked her into, we jumped a train in Wichita kansas, and we rode it to the next city and then we didn't realize we'd have to wait a couple hours, for one coming back. When we got home, everyone was worried and said well where were you and we said, well we jumped a train and we went to the next town then we jumped off but we didn't realize there would be a long time. Oh my gosh my mom and dad, they had not problem with me jumping on the train, it dragging my little sister Kaylene on it, they had a problem with. I think if I would have got killed they would have been okay with it but the fact that I drug, Kaylene on there they were about to shoot me but God dang that was fun.
Howard: Is that the one that became the nun?
Bill: That was the two oldest ones. Mary Kae, and June Marie became a nun, and Kaylene did not.
Howard: You were asking me about front desk. The way we ramp up front desk is you do it a step at a time. By the way, there's another neat product out there that I really like out there, rock the front desk. It's a really nice training video company, and that persons pretty cool. One of my clients Ryan Last just did a segment for you guys, on case presentation.
Bill: That was amazing, that was the second course he's done for us. How many have you done with us?
Howard: Just one.
Bill: Oh my god, you've to to keep up with Brian Laskin. Who was this Rocking the front desk? Who was that?
Howard: I don't know, her name. I think, if you just rock the front desk, I don't have any kind of business relationship with her or anything but I just think it's a really excellent training video. You know my associate Shelly Ryan, whom you met when you were up here. She's the best consultant in the United States, she's better than, I am or anyone else I've seen. Because she can win people over, and yet crack the whip, and she's been an assistant and stuff like that, so I have some great trainers on my team.
Bill: I love your stuff because it's all real world, so who can you deliver from your team for another real world, rubber hits the pavement, podcast?
Howard: I think Shelly would be pretty good to talk to. Kelly's my marketeer type, I drafted her because her dad was getting a hundred and fifty new patients a month, and he was non par, and had a half million dollar a year marketing budget, so she basically had kind of paid training for me, so I drafted her. I 've got two good ones.
Bill: Weill you deliver them both for a podcast with me?
Howard: Yeah, if you're okay. Aren't you piled up with those?
Bill: I have a waiting list of three hundred but I want to do it because I want real world. What I can bring to the table is I have been reading the message boards, four or five hours. I'm addicted to my product. I have the Dental Town app. I can't go an hour without checking that, so I'm addicted to my product. I still see patients now, twenty eight years, and I like to find good information. I mean I'm not going to deliver, fluff. There's so much fluff in practice management. I mean we all heard the deal.
Howard: We don't really deal in soundbites that much, Shelly keeps it real, so I think that'd be really great. It would be fun, to see you two talk.
Bill: Lets do it, and drag up your other friend who might of left dentistry. She was a rock star, for a long time.
Howard: Oh, Sandy Roth.
Bill: Yeah man, she was feisty and truthful.
Howard: I don't think she knows me from Adam, but I knew her and I really liked her stuff.
Bill: Great stuff. Then last question, because we're over one hour. Back to that ideal practice, since labor is your number one cost, is there any ratio, for every dentist, should there be two assistants, or one or three, a hygienist, one two or three? Front desk
Howard: I always think in terms of Peter Druckers result control. For example, a doctor asks, should add hire another assistant? I go,"How many extra operative visits could you see per day if you had another assistant?" He goes, "Two or more." It's a done deal, because you run the numbers and you go, you're making money, but you're not getting the four to one you know if you look in the actual statistics gross wages not including benefits twenty five-twenty seven percent. Now if you want to use Rick Curshners model remember, Lean in me.
You can keep gross wages, you just don't have a hygiene department. Get rid of your hygiene department, and he didn't have much of one and he got ten points off. For the typical practice it's there so you do want to see a ratio, because that's result control. To flip it, when you add that assistant, if you don't see the doctors production go up by at least fifty dollars an hour, you don't have result control. I always go from where you're at, if you add an assistant, do this. If you're over staffed and the statistics show it like you're over thirty percent, it begs the question but it isn't necessarily, certainly overstaffed, so when you see them fall off the statistics, you look into it.
I never conclude things just based on the statistics. The answer to your question is, every time you add a staff person of four to one, but you know hygiene is three to one right? Do you not add hygiene, hell you do, you get three to one you do it all the time. They'll oh my staff wages are thirty three percent, I go doc your cheekily fluoride genus all the time. You got a million patients, and you've got an associate but don't cry, because your staffs hourly percentage is high, look at your net.
Bill: What should the net be, what is a realistic net?
Bill: A realistic net is thirty five percent of collections, but there's lots of variables, and I think that's a realistic. If your having thirty percent or more or whatever, everything has to be ... but anyway, I've got clients with fifty percent nets, and I've got clients with, I suppose twenty five percent nets, and the idea is that they're moving the right direction. Someone with fifty percent net, usually, doesn't have a lot of hygiene.
Howard: I just want to end because we are two and a half minutes into overtime. I just want to end on one statement, is I hear so many dentists whining, and I'm like, "Look at your paycheck." Then go to the department of labor and economic statistics and so many dentists don't realize no percent income is the average dentist in america? What top percentile, of the three hundred and thirty million American's?
Howard: It's got to be in the top two percent or something like that I think.
Howard: Yeah so that dentist doing three fifty, that's in the top one percent. These dentists are in the top one percent income, don't work evenings or weekends and aren't going to get killed by a jackhammer or have a fall off the boom, and their working indoors with air conditioners and nice people, and your the king of your castle, and if someones dysfunctional you don't have to put up with them.
Bill: You know if you were in medical you would be beholden to the suits of the PPO's, most dentists are still independent. It is really a nice way to make a living and you know what there's always been bad news, you went back to this other thing. Tell me about a time there want some impending doom. I remember Abraham cane stomping around on stage, going you all are going to be bankrupt by nineteen ninety.
Howard: Is he still alive, he was from Phoenix.
Bill: I don't think he is.
Howard: He passed away?
Bill: He certainly dropped out of sight.
Howard: My favorite patient in today's office is this old man, he's bout eighty five and every time he comes in, I don't know, if he doesn't know he tells me every time and just repeating himself but he says, "You're so lucky." I always say why is that Bernie. He'll say, " I worked for fifty years in a machine shop, with six, ugly men. In a barn with no air conditioner, and you live indoors with the most beautiful women I've ever seen in my life, oh my God. I can't believe I worked with six men in overalls for half a century." I look at all my smiling staff and I'm like, "Man we got it made." On that note, we are at an hour and four, I've got to run but God dang, thank you so much Bill, for an hour of your time. I would so love if you would deliver your other two, Shelly and the other one, and just real world. If someone wants to contact you, how to they contact you?
Bill: They can Google my name, I come up pretty well to that. Bill Rossi. Bill Rossi at advanced practice management dot com.
Howard: It your email Bill Rossi, What's your email?
Bill: You know what, we just switched it, just Google my name that will get you the website, Bill Rossi, or my phone number.
Howard: The website is advanced practice management dot com.
Bill: Yeah, I think I'm Bill at advanced practice management dot com but it was Bill rossi, just go tot advanced practice
Howard: Advanced practice management is APM.I always email you at APM, at advanced practice management dot come. Them when you send me an email it always pops up in my porn blocker I don't know why that is.
Bill: If I do my b rossi, email are you getting that?
Howard: That was a joke. I think we were the two most handsome men ever on podcast in dentistry ever. Hey Bill, thank you so much for all that you do, for your clients for Dental Town. Your just a hell of a guy. I love you so much.
Bill: You too thanks for having me Howard thank you.
Howard: All right have a great day.
Bill: Okay you too, bye.