By Nona Naghavi

A lot has been said and covered by many before me. Ben has done a tremendous job hammering it into our heads that some things that we thought we should never do must be done in this day and age. I just want to share with you my own experience. I can only speak for myself. I understand this may not apply to everyone.

In 2011 I took a job in a busy practice in a location that was considered ideal: Underserved and not saturated. I learned a ton but ultimately missed living in a more urban environment. In 2012 I moved to a super saturated and overserved area with no jobs lined up.

Assumption 1: There are no jobs in saturated markets.

I agree that it’s not wise to do what I did but just for the sake of this article’s title, I would like to say that even though the assumption is that some states can guarantee your failure, I was able to not only find work but ultimately make more money than I did in 2011 while working less days. If you want to live in a town you love, close to family and friends, it IS possible, BUT you can NOT be picky.

In 2013 I found out about Young-Docs, now Ortho101. I did almost everything Ben recommended, as much as was plausible in my business model. One of the most important being signing up with Medicaid.

Assumption 2: Medicaid pays too low.

First of all, I get paid for just doing the consult. Can we say that about our non-Medicaid consults? Secondly, I have no problem with cases that get accepted, I still make money. (But I bank on majority that get denied anyway). I’ve learned to be efficient with my mechanics and finish on time. If the pay is low I pretend I had to write off some of the money because patient went MIA or moved. Don’t we have that happen in our posh offices some times?

Assumption 3: Medicaid patients will only start if it’s covered.

So where do you think I do my same day starts?

Assumption 4: I’ll have to use cheap brackets so results may suffer.

The forum is full of posts about how and where to get cheaper brackets (and not all are asking because they are implementing Medicaid. Some are buying for their posh practices).

Assumption 5: Rich people will appreciate my work more.

There are 2 kinds of poor people; 1) only poor on paper (but really rich), 2) truly poor. They constitute 100% of my Medicaid patients. I can’t tell the difference because they both show their appreciation the same way. Truly rich and entitled people will find flaws that don’t exist first and then maybe appreciate.

Assumption 6: Medicaid patients don’t show up to their consultation.  I just showed Ben my work schedule for a random day in September. 42 consults. School is in session mind you. 30 of them showed up. Even with the 12 no shows, wouldn’t you love to see 30 NP consults in 1 day?

Assumption 7: Medicaid patients break brackets and don’t brush. I’m tired of hearing this. At least once a couple of month there’s a post about how to deal with a high end mom not accepting the fact that her spoiled rich son is chewing rocks and brushing only once a week.

So in 2012, in the saturated town I moved to, I met a GP in a mommy and me class who immediately gave me 1 day a month in her office. In the span of 1 year I was providing Orthodontics for 10 different offices with any combination of 1,2,3, or 4 days a month depending on their patient pool.

Assumption 8: Medicaid patients will run off my ‘other’ quality patients. I don’t want my living room full of Medicaid patients: This is very personal but I’ll share it. I was a resident while pregnant with my first child. Unlike what I had planned for, I ended up with an emergency C-Section. Student, no insurance, no money. I will NEVER forget the stress I was under when presented with the hospital bill. I will NEVER forget the nice lady that came to my hospital room and said have you considered applying for Medicaid? Medicaid gave me coverage for ONE DAY only, my surgery day. I walked out with my baby. I was a DOCTOR on Medicaid that one day. There’s no “Them” and “Us”. Please treat everyone.

Assumption 9: Working in a GP’s office is a dead-end because:

You can get kicked out by owner at any moment: It’s in the owner’s best interest to help you grow and make the environment amenable to Ortho’s needs. Why would any GP introduce a disturbance into his practice only to destroy the good will he’s worked so hard for? Have I heard and witnessed horror stories? Yes. But I firmly believe that unless YOU are being a pain in the neck no GP will intentionally make life hard for you. Their biggest fear is you leaving and their patients’ continuity of care.

You’ll never get busy: I don’t know if you’ve noticed but at least most offices that I work for have expanded and become their own multi-provider clinics. So I have at least 3 if not more doctors referring to me within each clinic. Am I busy? Yes.

Assistants aren’t trained: Do you only hire experienced assistants for your traditional office? Can you afford it in your start up?  I had zero assistants for the first year. I did everything myself. Quite honestly I loved it, I didn’t have to correct anyone’s mess up, I was fast and I did not waste any of my materials. After that I got too busy and hired. I got lucky because in my area there are many foreign trained GP’s and Orthodontists who would gladly be my assistants. BUT, I have hired and trained from scratch too.

What about emergencies? I’m only there once a month: I’ve trained the GP’s assistants to take care of emergencies for me in between the Ortho days. I have NEVER driven to an office for an emergency call. Either the GP or their assistant has been able to take care of it for me.

How do I make appliances? Separator and banding is 1 week apart: I found a great lab who bands for me (extra charge but I’ve said goodbye to buying and fitting bands). Take impression and see you in 2 weeks or even 4 weeks. This lab is great. Appliances fit after 4 weeks no problem.

I can’t use appliances/iTero/iCAT that I want: Haven’t we learned we don’t need to buy SH*T we don’t need? How is this any different?

 I don’t have Dolphin or TOPS or whatever software: I still use the PPT template I created to make my composites. If the front desk is capable of giving an appointment using whatever dental software they have and produce a day sheet for me at the end of the day, that’s all the software I need.

There’s no Ortho TC: I’ve tried everything including presenting the financial contract myself in the beginning, all chairside. Now I have a head assistant that also doubles as my TC, all chairside. I noticed she had natural closing skills. I pay her $10 per SDS.  There isn’t much space to spare in most multi-provider offices so I learned to keep things simple. I don’t need a TC room. By the way, even if I owned an Ortho office, I will never do open bay for this exact reason. GP offices with separated operatories are great for privacy and discussing fees/OH/compliance issues chairside.

I can’t carry my supplies everywhere with me: Some offices will want to purchase and own the supplies anyway. Some you have to use a carry-on bag for (and hence take home a higher % so it’s well worth buying a bag for!). Is that really so bad? Are all your satellite offices fully equipped? You’ve never had to tag along some extra brackets/wires and such with you between the 5 offices you own?

Assumption 10: I will not take over another Doc’s cases. I want to start all of my own cases: Why? I never understood this. In my first job I took over hundreds of cases from someone before me. It was AMAZING to learn about the finishing phase of tx simultaneously as the initial phase. I saw what worked and what didn’t. I learned what NOT to do. It was rough but I came out of it like a soldier who had seen too much but was also that much wiser. I was getting paid AND learning at the speed of light, from someone else’s work. Some of the offices I’ve taken over since have had patients who are overtime but accounts are paid. I can tell you there’s no better motivation to learn how to simplify and streamline your mechanics in detail when you know you are not getting paid until you finish this case FAST.

Assumption 11: I have to open a practice right after graduation: My best advice to new grads is “Know Thyself”! Know your personality. I have nothing against established practices. The guys and gals that kill it were born with that personality. They would’ve been successful in any business. They just happen to be an orthodontist. But remember being the face of a practice leaves nothing private anymore. I see how people’s lives get wrapped up and consumed by the activity on their office FB page. From community involvement to marketing to games you have to play and the image you have to portray 24/7… if success means being in front of a camera all the time then be sure that’s you. You might be happier just associating and that is perfectly fine too.

Oh and best of all? I do zero marketing.