Less time, lower standards

Aug. 21, 2014
I figure that you've worked in many different offices, so I wondered what your experience has been regarding different insurance companies and treatment planning. 

By Dianne Glasscoe Watterson, RDH, BS, MBA

Dear Dianne,

I figure that you've worked in many different offices, so I wondered what your experience has been regarding different insurance companies and treatment planning. Most of the patients in my office carry insurance with a specific company, which I've been told doesn't pay much for prophies. Yesterday, the office manager announced a decision to reduce the recall appointment time for these patients from 50 to 40 minutes.

I guess they feel that, since these claims don't get paid as much, we shouldn't give the patients the same amount of time. I find it difficult to get everything done in 50 minutes. I'm not sure what to cut out if I have 10 minutes taken away. I did ask the office manager/lead dental hygienist what she thought we could eliminate and still provide the care we wanted to. She said we won't be eliminating anything; we just have to work faster. Have you had anything like this happen to you, and what did you do?


Other articles by Watterson:


I can understand the desire to shorten the appointment, because, apparently, if you're in network and take United Concordia you can only collect whatever the insurance company allows for a prophy. The office barely breaks even after they take out my salary. If they don't accept the insurance, they'll lose many patients.

Still, I feel we owe it to the patient to give them the same care other patients get. I feel like hygienists are viewed as robots -- like we can just work faster and still produce the same results. I wonder if the dentist will cut his restorative appointment time by 10 minutes too. I'm just getting very discouraged. I want to feel good about my job, but all too often I feel I'm cutting corners to stay on time. It's very stressful as I'm sure you know. I've been in dentistry for over 25 years and it seems like it's all about production and what the insurance companies dictate.

I feel that everything I do at an appointment is important -- medical history, oral cancer screening, perio charting, home care, prophy, treatment planning, talking to the patient -- and yet I'm being asked to cut corners to stay within a 40-minute time slot. It's hard to stay enthusiastic about this profession when your standards are constantly being compromised. Or am I overreacting?

Candace, RDH

Dear Candace,

No, I don't think you are overreacting at all. But the reality is that dental business owners are facing many financial challenges that do not have easy answers. The problems are not just in practices that are heavily into PPO dentistry. Even fee-for-service practices are having problems staying financially healthy as patients opt to go where their plans are accepted. Without a solid marketing plan in place, it has become increasingly difficult to keep a steady stream of new patients flowing into the practice.

The plans vary widely in reimbursement rates. Even the best plans rarely, if ever, pay 100% of the fee. As more dentists have become participating dentists, some plans have even reduced their already low reimbursement, making it more difficult for dental practices to be profitable. Make no mistake about it. General dental practices typically have high overhead expenses. All the bills have to be paid first, including staff wages, before the owner gets paid.

The time issue is a huge problem. Cutting the appointment time by 10 minutes reduces your available time by 20%. I do understand your dilemma. I'll share with you that I worked in a totally fee-for-service practice for many years, and we only got 40 minutes for prophies. Some days, I was praying for a no-show. The thing I cut corners on the most was the periodontal charting, unfortunately.

There were times I would make an argument for some patients who needed more time, especially smokers. The only time we got an hour was if the patient was a periodontal scaling or periodontal maintenance patient. A consultant then recommended that an assistant be hired to help in the hygiene department. The assistant's primary function was to help all five hygienists with periodontal chartings and developing of X-rays. Having this assistant was a tremendous asset.

Here are a few tips for you regarding efficiency. You have to look for ways to be more organized and efficient. First, think ahead and try to decide what will be needed for each patient at the next visit. If the patient needed BWS, I did not perform periodontal charting at the same visit. Second, use your power scaler liberally. Third, use tray setups. I had 10 of those plastic trays that I preloaded each morning with all of my disposables. This kept me from having to open so many drawers when turning over the room. All I had to do was reach in the cabinet and retrieve the tray.

Another thing I did was to put six chair covers on top of each other (we used dry cleaner bags). So when turning over my room, all I had to do was rip off the top cover. Six covers would get me through the morning. Boom. Done. Every minute counts. Finally, shifting the scheduling of the patient's next visit to the business desk will also save time.

The most productive and efficient model of hygiene practice is assisted hygiene. In this model, the hygienist has two mirrored operatories and is scheduled alternately in each room. A dedicated assistant performs many of the essential, yet nonproductive aspects of the visit, including operatory turnover, seating and dismissing patients, making the patient's next visit, assisting with the doctor exam, and patient home-care instructions. The assistant is always available to assist with periodontal chartings and suctioning with periodontal patients.

The typical hygiene patient will get 30 to 40 minutes of direct care from the hygienist and 30 to 40 minutes with the assistant (including room turnover). A typical day of assisted hygiene will provide treatment for 12 to 14 patients, depending on the mix or procedures, and the hygienist will be less tired at day's end than when he or she saw eight to nine patients in a solo model. Care will not be compromised if scheduled properly, and the hygienist will not feel like he or she is fighting the clock all day.

When comparing production between the solo model vs. the assisted model, the difference can be quite significant. For example, the average solo production per day is $1,400 (including doctor exams), and the average assisted production is $2,400. If we multiply the difference, $1,000, times 170 workdays in a year, that equals $170,000. After subtracting average salaries for hygienist and assistant, additional profit would be around $85,000. This is a conservative example. Many offices have seen even greater gains. If you would like to see a sample assisted schedule, send an email to [email protected].

My heart goes out to you. I know well the struggles with which you are contending. But in today's more difficult economic times, traditional work models are not the answer. Your office has placed a challenge before you. You can do this! Your office and patients are blessed to have you.

All the best,

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her website at www.professionaldentalmgmt.com.

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