Conflicted over fees

Feb. 13, 2015
Dear Dianne, My biggest dilemma as a hygienist is in communicating treatment needs to patients. I hate telling them that they need expensive root planing or other treatment. I want them to leave happy! What can I do to overcome this aversion to delivering bad news?


Dear Dianne,

My biggest dilemma as a hygienist is in communicating treatment needs to patients. I hate telling them that they need expensive root planing or other treatment. I want them to leave happy! What can I do to overcome this aversion to delivering bad news?

Cathy, RDH

Dear Cathy,

Your post contained one word that expresses to me the root of your communication issues: expensive. Evidently, you have great empathy for people and understand what it means to be financially burdened. But if we dig a little deeper, there may also be a personal discomfort with what you consider to be high office fees. It's not uncommon for staff members to feel this way. It may even be possible for staff members to feel that the services they render are not worth what the patient is being charged. That's a big problem.


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As a consultant, I understand that staff members are often not aware of the high overhead expenses in operating a dental practice. Some staff members do not know what the word "overhead" means. Overhead expenses are all the bills owed by the practice every month just to keep the doors open. There are fixed expenses (meaning they are the same each month) and variable expenses. All the expenses, including the staff members' salaries, must be paid before the doctor gets paid.

You may find this hard to believe, but I've consulted in practices where the overhead was so high that the doctor did not get a paycheck for a period of time. In one practice, the doctor made less money than the hygienist. How would you like it if you owned a business and everybody else got paid except you, or you had staff members who made more money than you?

You might be wondering how a dental practice could find itself in such a dilemma. There are several reasons, one of which is having fees that are too low. Fee setting is one of the most difficult aspects of practice management for many doctors. Quite a few doctors struggle with raising fees, yet they know their expenses rise every year. The intrusion of PPO/HMO plans into dentistry has only exacerbated the problem of high overhead, because discounted reimbursements influence the overhead percentage. Revenues are balanced against expenses, and when revenues are not high enough to counterbalance expenses, the business gets in financial trouble.

Part of the reason that staff members do not understand about the high overhead associated with operating a dental practice is because many doctors do not share that information with staff members. Every practice should have a monthly staff meeting where several of the key metrics are shared with the group, including gross and adjusted production, revenues, hygiene department production, number of new patients and patient transfers, dental supply expense, lab expense, and overall overhead. If business owners want staff members to have business owner mentalities, they must be willing to share some of the business statistics. Otherwise, staff members can have erroneous views of the health of the business.

I've consulted in practices where staff members complained to me that they felt they were not being paid enough or that it had been a long time since they had had a raise. I can certainly empathize with that sentiment. But what they don't realize is that in some situations, the staff salary percentage of the overall overhead is already abnormally high, and that to raise the salary expense without a corresponding rise in revenues is financial suicide.

Just to present a balanced discussion, some practices do have abnormally high fees. If the fees are too high for the particular geographic area, the market will not bear it, and the practice may have a difficult time staying solvent.

The point I'm making is that if the office fees are not high enough, the health of the business will be jeopardized. So when you feel the fees are too high, take a deep breath and remind yourself that your own personal compensation is possible because of those fees. It is acceptable to have an opinion about fees, but it is not acceptable to let that opinion interfere with informing patients about needed dental care.

As an exercise, I'd like for you to pretend you are the patient. In the course of your visit, you find out that you have a chronic, inflammatory disease in your mouth that is destroying the bone that supports your teeth. The one thing you know is that you don't want to lose your teeth. Would you want your hygienist to speak to you confidently and positively about how the problem can be brought under control, or would you rather the problem be minimized or not even addressed? As the patient, would you feel good if you detected that the hygienist was conflicted or struggling with speaking about the issue?

Business assistants are often faced with patient remarks about fees. Here's what I teach them to say: "I understand why you might feel that way, but please understand that our fees reflect the quality of work we do here. We will only give you the highest quality." I want them to say it with all sincerity and conviction.

In any business, it is important to understand the mindset of the customer. The mindset of our customers/patients is that all of our fees are high, no matter where the fees fall in the particular ranking. We have to have fees that are not only high enough to pay the expenses (including staff member salaries) but also to have a cash flow cushion for unexpected expenses and provide the owner with adequate compensation to pay his or her bills and support a family. It's a huge responsibility.

I hope you understand that the services you and the doctor provide are valuable to the patient's oral and overall health. Try to move past any negative perceptions you may have about fee levels, and speak confidently and unwaveringly about any dentistry the patient needs. Resist the urge to judge the patient's financial state. Don't think of it as "bad news," but rather how the patient can be helped. That's why we are here ... to help people. The news is bad news only if there is no way to turn the problem around. The news we give is good news - we can fix this! My experience is that if the patient likes and trusts us, he or she will be amenable to just about any treatment we propose.

I sense that you really care for your patients and empathize with them personally. But don't let your empathy for your patient turn into a negative for your practice. Think of yourself as a cheerleader for your practice. The role of the cheerleader is to support and inspire the team and rally the crowd. Your role is to support your team and "rally" your patients by helping them understand how their dental needs can be resolved with the excellent care all of you are prepared to deliver. RDH

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