Only 5% charge a fee for the first offense, while 39% charge a fee after the second missed appointment. 20% of dentists charge after the 3rd missed appointment.

With the current economic conditions, The Wealthy Dentist decided to ask dentists if they have been charging for missed appointments.

Boston’s Pilgrim Hospital is in the news this week for reveling that in the first 10 months of 2011 patients failed to attend almost 17,000 appointments. Thats about 49 missed medical appointments for every day of the year.

“Time is money!” complained one dentist, and he is right. A missed appointment is an appointment that can be filled by other patients. Missed appointment fees ranged from $25.00 for the first no-show to $2,500.00 after the third missed appointment. The average fee is $75.00.

The following dentist’s comments were selected to share how dentists are handling missed appointments –

Pre-paying is popular …

“We ask the patient to pre-pay for future appointments.” (Illinois dentist)

“Repeat offenders are put on ‘probation’ where they must pre-pay (the full price, non-refundable) before we will schedule them again. This way we don’t ‘fire’ them, they either pre-pay or leave the practice. They are usually on ‘probation’ until they consistently show up.” (Kentucky dentist)

“We have them pay before the appointment and if they break the appointment, the fee is deducted from their account.” (Missouri dentist)

“After three missed appts we will not reschedule unless they prepay in full for whatever the appointment is for. It works great. We have a great practice and people know the value that they receive here.” (Colorado dentist)

“We ask the patients who no show for 2 appts or more to prepay for further visits.” (General dentist)

“We just charge them little more when they come next. Also if they are entitled for any offers or discounts don’t give them that.” (General dentist)

Confirming helps …

“Confirm. Confirm. Confirm.” (General dentist)

“Have your patients give you the cell number where they receive texts and text them their appointment. Works like a charm.” (California dentist)

“We confirm by phone, email and text message.” (General dentist)

“We double book or call patient the morning of appointment.” (California dentist)

“We send a sms reminder the day before the scheduled appointment.” (General dentist)

Same day or on-call appointments only …

“After the second time we choose the option of putting the patient on our short call list only.” (Georgia dentist)

“We don’t give 3rd time offenders the opportunity to schedule in advance. We put them in our ‘Short Notice Club’ and call them when we have an opening or they can call to see if they can get in that day.” (Oklahoma dentist)

“After 3 missed, the patient must call on a day they would like to come in and see if there is an appointment available.” (Pennsylvania dentist)

“We don’t “fire” them but put them on a VIP list where we call them when we have a same day appointment available.” (New Hampshire dentist)

Fire them …

“My letter to the patient who I am dismissing is actually very nice. It states that our priorities do not match and that they would be better served by another dentist and to please let us know where to forward their records. A lot of times, the patient begs us to let them come back to the practice and they become our best patients ever about being there for their appointments even in bad weather, etc.!” (Alabama dentist)

“We send three letters and then dismiss patient with a 30 day emergency window so they have ample time to find a new dentist that will be more conducive to their schedule.” (Missouri dentist)

“You must get rid of them because you can not afford them. The other thought is to give them a stand-by appt. They may have to wait a while to be seen.” (North Carolina dentist)

“After a new patient reschedules/misses an appointment twice, we fire/do not reschedule. When existing patients break numerous appointments we notify them to call us on a day when they have extra /free time on their schedule and we will see if we can work them in at that time (this way we are not blocking an actual appointment for them). The best approach would be to require a credit card at time of scheduling to hold the appointment.” (General dentist)

How do you handle missed appointments? Have you ever “fired” a patient?

Dental insurance may be one way to attract new dental patients, but a new dental marketing player has emerged in 2011: daily deal offers.

According to Dan Hess, CEO and founder of Local Offer Network, approximately 9% of all offers on daily deal websites in November 2011 were for dental work or some form of medical treatment, up from 4.5% in the beginning of 2011.

USA Today reports that approximately one out of every 11 deals offered online is for a health care service, according to data compiled by DealRadar.com, a site that gathers and lists 20,000 deals a day from different websites.

Dental deals are the most popular among users of daily deal websites.

Many attribute the growth of the use of daily deals in the healthcare sector with sites like Groupon, is the fact that 45 million Americans under 65 have no dental insurance coverage, and another 46 million have no health insurance coverage, according to CDC statistics. The daily discount deals offer many uninsured Americans a way to visit the dentist or doctor.

Some argue that a one-time visit to the dentist because of a deal coupon does not create a lasting dentist-patient relationship, or attract the right type of dental patient. Good long term dental marketing studies are hard to come by in dentistry.

However, the economic potential can be great.

The owners of Robust might agree. Robust is a wine bar and cafe in St. Louis, Missouri that ran a Groupon deal for $18.00 and sold 4200 deals for a potential $75,000 in revenue to be shared with Groupon. As important as the revenue was to Robust, their Groupon deal gained national news attention with tons of free marketing for their business that they never would have been able to afford.

Dr. Gregg Feinerman, an ophthalmologist who runs Feinerman Vision Center in Newport Beach, Calif told USA Today about his experience with Groupon, “We reached a whole new demographic who otherwise wouldn’t find us.” He offered a 58% discount on Lasik eye surgery. “It’s a better way to market,” he said.

He used Groupon as a way to bring in patients under 30-years-old with the hope that they would recommend his services to friends and rate him on review website Yelp. A good review might persuade someone else to visit his office, Feinerman said. He charges $5,000 for the surgery on both eyes; a price that he said can be “overwhelming for 20-to 30-year-olds.”

Is this brilliant marketing or just clever pricing?

Feinerman approached Groupon about listing the eye surgery for $3,000. Groupon, which is based in Chicago, pushed him to lower the price to $2,100. Dr. Feinerman got exactly the type of patient he was looking for in Thomas Cho. Cho, 29, bought the offer and after the surgery wrote a review on Yelp. He gave the vision center five stars — the highest rating on the website.

Cho said in an interview that his health insurance plan only covers 20% of the regular price of Lasik since it is considered a cosmetic procedure. He would have paid about $4,000 if he had used his insurance discount. Cho decided to buy the Groupon, paying $2,100 initially. After consulting with the doctor, he upgraded his surgery to an all-laser procedure for $1,000 more. At the time, Cho’s credit card issuer was offering a 20% cash back promotion on Groupon purchases. In all, he saved more than $1,300.

We have written extensively on Google Offers and Groupon ad design and strategy. Now it is time to hear back from you as to both the short and long term results of the new dental marketing vector!

For more on the USAToday story see: Uninsured turn to daily deal sites for health care.

“If the economy improves, as it should, we all should do better in 2012!” said one dentist.

In fact, when asked what they expect for 2012, 77% of the dentists who responded to our survey anticipate a better financial picture, while only 23% expect 2012 to be a bad year.

When asked about the past two years, 42% of the dentists said 2011 was economically better than 2010. However, for 40% of dentists, 2011 was economically worse than 2010. 18% saw no difference economically between 2010 and 2011.

Here are some dentist comments:

Dental marketing worked…

“We plan that each year will improve over previous year due to addition of an associate and definitive marketing strategies utilizing the Internet Dental Alliance web sites!” (Oklahoma dentist)

“We didn’t have a better year by mistake. It was due to being proactive and using targeted dental marketing.” (California dentist)

“We streamlined our dental marketing efforts, increased our marketing return on investment, focused more on internal marketing, and tightened our belts on our overall office expenditures. We will end this year with more new patients and economically much better than the previous 3 years. We are riding out the economic storm fairly well.” (Ohio prosthodontist)

“I feel our picture is 50% real and 50% what’s in our head. If we stay positive and use services like yours we can make our results better than average. How much better depends on our head and the help we get.” (Urgent care dentist)

Implementing new strategies helped …

“We are staying afloat because we offer a very wide-range of services for a General Dentist – Invisalign, Sedation, Implant placement and restoration, CEREC, most Endo, Perio, and Oral Surgery. Without this broad offering, we would be doing much worse.” (General dentist)

“We are down 5% but we completely remodeled our office doubling our space, had 5 of 8 staff members pregnant, losing 4 of them, worked through the construction dust and noise, and were still only down 5%, so I am happy with 5% downturn. I look forward to 2012.” (California dentist)

“In order to turn things around, I have completely had to change my practice. I have a management group I am now using and am revamping office systems. We are working hard to maintain the high level of care we have always offered, but am now participating as “in network” with dental insurance, and am now thinking about profit centers and time management. We are trying for a balance that doesn’t diminish our ability to do awesome dentistry, but it will be more difficult with the restrictions that insurance companies place on treatment. Illinois has been hit hard by the economy, with the “reported” unemployment level finally getting down under 11% for the 1st time in 3 years in December with the seasonal Christmas hirings. The actual unemployment is around 21%.” (Illinois dentist)

“I spent time creating additional avenues of wealth.” (General dentist)

“I will continue as I have through thick and thin, modifying as I see necessary, continuing to update skills, and taking very good care of my patients. While this year was a downturn, compared to many of my local peers, it was truly a minor one.” (South Carolina dentist)

“I am dropping Delta Premier. I tried it this year and I can’t give that 25-35 percent discount.” (Illinois dentist)

Looking to 2012 for relief …

“Our goal is to increase by 30% in 2012.” (New Jersey dentist)

“The first half of 2011 was the best ever. The second half saw a decrease relative to 2010. The trend is for 2012 to be flat, so I am playing it very conservative right now.” (Virginia dentist)

“They must improve in 2012!” (General dentist)

“In 2012 I definitely need to change how I do business in regards to PPOs. I use to be an all fee-for-service practice. That dwindled, and now I am busy, but not profitable. (California dentist)

“If President Obama loses we’ll see a much better economy.” (General dentist)

The Wealthy Dentist would like to thank all the doctors and specialists who have participated in our dental surveys over the past year. We find your insights and comments invaluable and we appreciate the time you take to offer feedback.

We wish all of you a very prosperous 2012!

The report complied data from the CSHP’s 2001 and 2009 New Jersey Family Health surveys on children ages 3 to 18 who received no dental services within a year.

The study found that children with employer-sponsored or privately purchased dental insurance were much more likely to receive dental care than children without dental insurance or even those covered by publicly insured programs like by Medicaid/NJ Family Care.

According to Rudgers University news, the report also pointed to well-care doctor visits as an important indicator of the likelihood of a child receiving dental care, possibly because of efforts to increase dental referrals in managed care plans and the expansion of dental care in federally qualified health centers.

“The odds were three times as great for children who did not have a well-child doctor visit in the past year to not receive dental care as those who visited a doctor,” said José Nova, research project coordinator and lead author of the study. He noted that care for under-served children could be improved with expanded health coverage under the Patient Protection and Affordable Care Act.

Reuters estimates that 45 million Americans do not have dental insurance.

To read more on this report see: Rutgers Study: When it Comes to Use of Dental Services, not all New Jersey Youngsters are Equal

According to the ADA, independent dentists reported paying full-time dental hygienists $33.90 per hour in 2008.

Considering the current economic environment The Wealthy Dentist decided to conduct a survey asking dentists if they pay their hygienists an hourly wage or if compensation is based on commission.

It seems most dentists still pay their dental hygienists an hourly wage, but some feel paying on commission is more fair. Said one dentist, “Hygienists are worth their weight in gold!” Another dentist disagreed saying, “Practices couldn’t run without them, but the current economics barely breaks even at best … hygienists seem to think they are cash cows for the office and fail to recognize the support and facilities the utilize.”

It’s an interesting economic issue. Click on Play to hear more of what dentists say about paying hygienists –

How do you pay the hygienist in your practice?

Of the 20 fastest growing occupations in the US economy, half are related to healthcare.

Healthcare is experiencing rapid growth, due in large part to the aging of the baby-boom generation, which will require more medical care. As healthcare costs continue to rise, work is increasingly being delegated to lower paid workers in order to cut costs.

For example, tasks that were previously performed by dentists are now beginning to be performed by dental hygienists and dental assistants.

As dentists‘ workloads continue to increase from treating the aging boomer population, it is expected that the demand to hire more hygienists to perform preventive dental care will grow as dentists will want to spend more time working on more complex dental procedures.

There is also the growing situation of not enough dentists to provide adequate care in rural areas where hygienists are needed to fill in the gap. According to the Center for Rural Affairs, in 2007, approximately 15 percent of rural residents were 65 years of age or older, 25 percent greater than in the nation as a whole.

The U.S. population of those 65 or older is predicted to double by 2030, reaching 20 percent of the U.S. total population, and the fastest group age living in rural America are residents 85 and older.

The average median wage for dental hygienists is $32.81 hourly, $68,250 annually with the best employment opportunities following the population size of states. New York, Texas, California, Michigan and Florida employ the most dental hygienists.

See: Occupational Outlook Handbook, 2010-11 Edition — Dental Hygienists

In a report by Sageworks, a leader in the financial analysis of privately-held companies, privately-held dentist offices have seen sales in 2011 decline about 3 percent after posting ongoing-though-shrinking gains in their top lines throughout the recent recession.

Sales growth rates for dentists in 2008 and 2009 were 5 percent and 15 percent, respectively, but dipped to 1 percent growth in 2010 before this year’s decrease.

Forbes.com reports that profit growth, too, has weakened.

Dentists have worked to keep costs and overhead down which has helped them maintain one of the highest net profit margins of private industries over the last 12 months, according to Sageworks data. Dentist offices had a 13.84 percent net profit margin in the 12 months ending Sept. 3, 2010, compared to the net profit margin of 14.15 percent in 2010.

The “2011 Survey of Dental Care Affordability and Accessibility” reported that 77% of the US are without dental care and put off visits to the dentist because of the cost of that care.

As the economy continues to crawl, more people may further opt to skip regular check-ups with their dentist because of increasing out-of-pocket expenses. Dentists will continue to struggle to maintain their profit margins, while trying to attract new dental patients.

It’s a vicious cycle that doesn’t look like it will be ending anytime soon.

For more on the Sageworks report see U.S. Recession Effects Gnaw at Dentists’ Business.

In many of The Wealthy Dentist surveys dentists have complained of career burnout.

Burnout is considered either emotional or physical exhaustion, usually caused by stress at work. It was initially described in the 1950s by Hans Selye as ‘the nonspecific response of the body to any demand made upon it and discouragement in the work setting’.

According to the U.C. Irvine report, burnout is viewed also as a complex of psychological responses (strain) to the particular stress of constant interaction with people who are in need. Differing from other interactional symptoms related to job stress is the effect on others seen as a depersonalization of clients.

Symptoms of Burnout -

1. Negative Feelings.
Feelings of disillusionment and being ‘stretched too thin’. Feeling that you aren’t making a ‘difference’ in your approach to lifelong goals. Other feelings of burnout are the feeling of being ‘run down’, easily frustrated and feeling that you are unable to concentrate.

2. Interpersonal Problems.
Your tolerance level drops as the burnout grows and you find yourself increasingly unable to handle social interactions. You begin to dehumanize your relationships by thinking of your dental patients not as people but as objects.

3. Physical Manifestations.
Burnout shows up physically as exhaustion, muscle pain, headaches, insomnia, respiratory illnesses, gastrointestinal disorders, depression, and hypertension.

4. Substance Abuse.
Often people suffering from burn-out will self-medicate their anxiety, depression and insomnia with drugs or alcohol.

5. Inefficiency at Work.
Burnout causes productivity to wane as you become less effective overall, either by hiding in your office or staying away from work more often.

Remedies for Burnout -

1. Take a Two Week Vacation.
Quite often by distancing yourself from your work you will be able to make some decisions on things you can do differently to alleviate stress when you return to your dental practice.

2. Cut Back Your Work Hours.
Sometimes burnout appears from an unwillingness to delegate job duties. Consider cutting back on your work load by delegating tasks you don’t enjoy and consider cutting back your dental practice hours if you can.

3. Schedule Time For You During the Day.
Make sure you always take a lunch break. Make it at least an hour and a half three days a week and schedule some light exercise for the last half hour like a brisk walk around the block or a yoga class.

4. Put Your Health First.
Go to bed at the same time every night and work on getting enough sleep. Look at your diet and see where you can cut out high sugar foods, and make time to relax with good friends on weekends.

5. Write Your Thoughts Down.
Some people find that keeping a journal at home and expressing your feelings of frustration on paper can go a long ways towards helping you deal with burnout. Commenting anonymously on this blog might even help too.

The most critical thing about burnout is to recognize it’s a shout out from your exhausted self. Try changing things up a bit in your life to break out of your routine. Come into the office thirty minutes later, drive a different route to work, learn a new hobby, or work on something you love. Take a break and list all the reasons you chose dentistry as your profession in the first place.

Have you ever suffered from burnout?  What advice would you give dentists for dealing with burnout?

In the Los Angeles Times article, Nagaraj Murthy, a dentist in Compton for the past 32 years, states that ever since California cut back dental coverage, he has lost about half of his adult patients because they don’t have money to pay for dental treatments. He doesn’t charge these patients for preliminary comprehensive exams but said he can’t afford to provide free dental treatment.

The highly anticipated healthcare reforms are not expected to help.

California’s Medi-Cal program no longer pays for X-rays, root canals, dentures, fillings or cleanings. As a result, some dental patients are having their teeth pulled instead of repairing or replacing them.

The National Institute of Dental and Craniofacial Research states that 12% of U.S. adults 20 to 64 have not been to the dentist within the past 5 years.

For more on this story see: Reduced State Dental Benefits Create Dire Situation for Patients.

The New York State Association of Counties has endorsed the ProAct Dental Network Card program that provides cardholders with information they can use to locate dentists who have agreed to charge relatively low fees for dental services.

In Illinois, through a partnership with Careington International, a dental discount card can help patients save up to 50 percent on selected dental services, and 20 percent on orthodontic services.

The discount cards typically work through a network of dentists who have agreed to reduce the cost of their treatments to cardholders. This sets a rate of treatments that appear to reduce the cost to patients considerably.

Some dental cards offer a percentage off of the amount the dentist usually charges while other cards set the fees for a specific amount of money. The dental discount cards charge either a monthly or annual fee and will usually last for one year.

The main thing to understand is the difference between a “Discount Dental Plan” vs. a “Dental Insurance Plan.” Over the last three years the Insurance Plans… which have always been marginal as far as benefits are concerned, have lost enrollees as unemployment has topped 9%.

Many people have been forced to enroll in “Discount Plans,” again with marginal benefits.

For the doctor in either plan the issue is dental marketing for new patients. The discount is the dental marketing cost you, the doctor, pays to acquiring the new patient lead. From their it is up to you and your team to screen for financial capability and do an outrageously great job on case presentation on qualified patients.