I recently read the article Key Performance Indicators by Charlene White in Orthotown magazine. Taken at face value, the article is an iteration of “average numbers” though it’s not entirely clear from whence these stats come (I assume the JCO and AAO but who knows). However, taken in the context of the online conversations and the prevalent orthodontic group think this article seems to be yet another indication of how we orthodontists, as a group, strive to be mediocre. We much prefer to focus on average than to talk about what is possible and this seems to be because we are terribly uncomfortable with the idea that some among us are able to do so much more than average. Furthermore, instead of holding up the peak performers for examination and emulation, we orthodontists do everything we can to justify our pursuit of mediocrity and relish the chance to explain why anyone who is “over performing” must be doing “bad work, running a mill, not caring about patients or just in it for the money” (as if the rest of us don’t care about getting paid). Why is this? I have my theories but discussing the why in the past has been upsetting to readers and a distraction so let’s just stick to the what for now. In that vein, I’d like to go through this article and the stats suggested as good guidelines so that we can discuss a few of them in terms of what is possible based on what others are already doing. This, in my opinion, is a far better set of guideposts for anyone who wants to elevate their practice.

1. 165 days is a ton of days to work to produce 1.485 million dollars. I know that the numbers floating around for the average orthodontic office range from 1.2 to 1.4 million in collections a year. That’s 3.5 days a week, 47 weeks a year or $424,285 per day a week worked (meaning for every day a week the average practice in this article works, they produce 424 k). I know that this “average orthodontic practice size” has permeated the psyche of the vast majority of orthodontists and is taken to mean “normal”. However nothing could be further from what’s possible (and what is possible is what we should focus on). It’s true that a million-dollar practice used to be a big deal… in the 1980s, but these days we should be doing far more given the improved technology we have to work with and it’s especially true for those of you who just gotta have the latest and greatest tech that costs you so much money. I personally know a great many owner-operator, solo-practitioners working out of one, moderately sized location with a middle of the road fee who produce over 4 million dollars a year. I know dozens of these practices where the owner/operator produces over 6 million a year (and several do more than that). To be clear I’m talking about production per provider numbers not per practice numbers (where there are multiple doctors). Oh and most of these folks work 3-3.5 days a week, 40-45 weeks or less a year. That’s 120-135 days a year, not 165 and 3.5-5 times the production per day suggested in this article! That is a huge difference my friends. But why does it matter so much? 3.5 days a week is not a ton of days to work? What’s the big deal? Well, the big deal is that patient days, the days the doctor is rendering treatment, are the most expensive things you do. The more of them you have the higher the overhead so the key number here is production per day a week you see patients. Of course staff is expensive and buildings are expensive and equipment is expensive (so having less locations is a big plus) but the best way to look at all this is your production per patient day. In my world (and among the orthodontists I associate with) the target we shoot for in an office with 7-8 chairs and a middle of the road fee is to produce 1.5 to 2 million dollars per day a week you choose to work. Meaning that if you work three days a week you should produce between 4.5 and 6 million dollars depending on your personality, comfort level and desire. Of course if you have more or less chairs and/or more or less motivation you can scale these numbers to suit you (but they will still be much greater than the “average”). The upper limit I’ve seen is 3.3 million in production – I’ve never done that but I know someone who has and this is very exciting as it gives me something to shoot for. Notice that instead of putting down someone who’s doing more than I can I am happy for them and want to emulate their success – try this sometime, it’s a refreshing and rewarding alterative to the normal attitude we orthodontists take when we encounter a larger practice. Anyway, if you can get your head right and learn from those who are already doing this the two biggest benefits to producing more in less days is 1) a drastically reduced overhead percentage combined with much higher collections which means more money in the bank and 2) much more quality time with your family (and the money to do fun things). The cost of such awesomeness? Nothing but adjusting your mindset and attitude! If someone else is already doing it then it’s probably possible.
2. While I will agree that we want production to exceed collections I believe that it’s foolish to plan on this happening incrementally instead of exponentially. A 10 percent increase is great if you’re already producing/collecting 4+ million a year but if you’re only collecting 750k and you’re happy with such a small increase then you’re selling yourself short. I can’t tell you how many times I’ve met people who were collecting a million bucks or even less and watched them explode. I’ve seen dozens of cases where within 3-4 years of a doctor getting their head right they went from 1 MM a year to 3 to 7 and even to 12 million in collections with increases in production/collection that were 100-300x their previous year. The information to make this happen is out there for all to see already. Most of the time this kind of growth occurs for ProOrthoFE members but I know several orthodontists who took the information available to everyone and made these kinds of leaps all on their own. You can too. It’s just a matter of releasing the old “standard” and embracing what is possible instead of what is average. What have you got to lose? If you shoot for these kinds of numbers and you only get half way there you’ll still be killing it! I want nothing more than to see you succeed. An incremental mindset will arrest your performance when you think about new patient exams and starts and anything else in the traditional way. Ten percent of not much is not much!
3. Worrying about or trying to quantify net production per start is just plain useless. Is it early treatment? Is it a double impacted canine case? How long do you take to finish a case doctor? How many overtime patients do you have? Have you run a “active patients with a zero balance report” to find out? How much unused capacity do you have? How many starts per month do you have? All of these questions have a bearing on what “good production per case start” means. As I’ve mentioned many times before I’ll be doing braces for $2998 and be very profitable because of my market position and the resulting ability to choose which cases I will treat. Think about these numbers people throw around and don’t just swallow them whole. I firmly believe that numbers like this impose a severe handicap on the modern orthodontist.
4. 1.5 starts per day is good (or even average)? On what planet? How can we continue to believe that this is the case? How can we aspire to such a low number? Yet, because we collectively believe this to be good we have this self-imposed ceiling/deserve level that cripples the average orthodontic practice and makes us feel justified in making, at best, questionable business decisions that seem normal to our groupthink minds.
5. While I’m all for a low 30/60/90 AR for both patients and insurance, this number is arbitrary in and of itself and is another handicap. Because of this ubiquitous fear of “getting screwed” we set policy to avoid that rather than to prosper. In other words we run off a ton of people who would pay us in order to avoid a few who will take advantage. Think about it. If you are in your office performing your most expensive maneuver (a patient day) and a patient comes in and wants to start treatment, why wouldn’t you do everything you can to make that happen. Your cost is minimal – or it should be if you’d stop using expensive brackets when the less expensive ones work just fine and YOU NEVER FILL THE SLOT SO PRECISION  IS USELESS – so what have you got to lose by putting braces on? Think about it a different way. Which is better? 98 percent of 1 million or 90 percent of 3? You don’t have to be a math major but you do have to have your ego in check to see the obvious flaw in the “low AR is always better” mantra. You do have much more control over your insurance AR so that should be very low but stop worrying so much about a couple percentage points when it comes to patients, open up your financing (or even, heaven forbid, lower your fee) to net out a slightly lower percentage of a much larger number. Just remember the bank account is all that matters – if the number in your account is getting bigger that is good, if it’s getting smaller that is bad. The rest is fluff.
6. Having numbers for how many staff you should have per dollar amount collected is another arbitrary way of looking at things. First and foremost, there are a ton of assumptions built into these numbers. Do you think it makes a difference for these admin staff numbers if you schedule chairside vs at the front? What about if you have a policy of “no patient leaves the office without an appointment” as opposed to telling patients “call us after you talk to your mom and we will make an appointment”? I can tell you it makes a massive difference and these are just two of the most obvious reasons such staffing numbers are bogus. Besides, who says we have to have a treatment coordinator anyways? I’m pretty sure this is just an artificial construct that someone came up with and the rest of us copied. I’ve been without for a couple years now and I can tell you chairside assistants can do the job just fine. Speaking of chairsides, do you think it makes a difference in your staffing needs if you use Herbst appliances, steel tie your wires in, make impressions instead of using intraoral scanners, have 120 appointment types, 100 procedure codes, 50 different wires and 45 different ways of wearing rubber bands? You damn right it does! The simpler your treatment and scheduling systems the less staff you need and the more patients you can see per day. What about the way the doctor acts? If you talk every mom and patient to death, spend an hour in the new patient consult, ignore assistants when they call you to the chair because you’re on Facebook and constantly run behind then you’re a big drag on how many patients can be seen per staff per day. In my world 20 patients per chair per day is the norm and higher is very possible. Do the math on what that means in terms of time per patient and you’ll see. BTW, turning over chairs and setting them up and getting the next patient is the big time suck in most offices as I’ve discussed before here on OrthoPundit.
7. Observations are crucial to your practice health. Make sure you tell every dentist, physician, mom, patient, person you meet in Walmart, whoever something like this: “We love to see kids seven years old and older. We don’t care if they have straight teeth, crooked teeth, baby teeth or adult teeth, we want to see them. We don’t like to put braces on that early but we sure like to get an x-ray and evaluate the growth and development to make sure those pesky baby teeth don’t cause problems that could be easily avoided. Many times we can get a good result without even using braces and that makes me happy. You don’t need a referral. Just come see us!” Then see them, in person every 6 months. By doing so you are helping patients, building a bond, providing an awesome service and insuring the future of your practice. See them in the open bay or in the records chair – there is no need to use the TC room for this. Make the visit fun and talk to mom about what you are looking for and why. I cannot stress the value of observation patients. Every single one is vital. More is better.
8. Overtime patients are practice killers. The goal is zero overtime even though this is not always possible. Be sure to talk about overtime patients in the morning meeting because what you focus on improves. Doctor, quit messing around and take the braces off if the patient is happy, if nothing is changing, if they are noncompliant or even if things are not working the way you think they should. Get the braces off. Now. See how it goes. You can always put them back on for free if that is what needs to be done but dragging out treatment for months and months and months is counterproductive. At minimum take a braces vacation and change it up a bit.
9. Every patient day should be a carbon copy of the one before and the one after. To allow your patient numbers to rise and fall depending on the day is to guarantee chaos will ensue for lots of reasons. This is an easy thing to avoid if your office manager looks in the future and gives days for future appointments in the morning meeting.
10. Broken brackets are a pain in the rear and I discussed this in a blog a couple days ago.
11. Overhead is another random number. If you focus on production per patient day and get your head right then an overhead of 40% is not difficult to achieve. 50% is easy. The key to getting there is to hit big production numbers – it is very difficult to shrink your way to greatness. In other words, saving 2 cents on cotton rolls will not get you to such a low overhead, only producing will! This is not theory. Shooting for a 60 percent overhead is just plain silly as it justifies what we are doing instead of forcing us to do what we should do – what we can do.
12. Collections per patient visit and production per patient visit are irrelevant unless you are at capacity (and I only know a couple people who are there). You have to look at an orthodontic practice like an economist not an accountant. If you have excess time then it doesn’t matter what you collect per visit. In fact this number can give a practice that is performing poorly a false sense of security and is thus very dangerous because they can still point to high collection rates per patient even if they see very few patient and collect very little overall.
13. Case acceptance is irrelevant. The number of starts are all that matter as discussed many, many times before. It’s about runs not batting average after all.
14. Running on time is crucial. You should accept nothing else and you should lead by example doctor. I’ve discussed this many times on OrthoPundit.

Just because you can measure something doesn’t make it useful and just because someone says a number is important or the industry standard is X doesn’t make it so. The same goes for what I’m telling you here. The important thing is to use your own brain and evaluate what you’re being told instead of just going along with the way we have always done it. You can do it. I believe in you. Now you just have to believe in yourself!

Have a great weekend.