Marc Ackerman

Ben Burris

We have discussed repeatedly our belief that the average fee for orthodontic treatment will trend lower. This prediction has been met with shock and horror from the majority of orthodontists who automatically assume a lower fee means lower “quality”, a terrible office space, the wrong kind of patients, less profitability and being overrun by “those people”. It’s funny how a different perspective can impact one’s vision of the future if you’re open to it. Far from doom and gloom, we foresee lower prices leading to much greater market penetration due to increased affordability and this leading to increased profitability and sustainability for the orthodontic enterprises who understand what is happening.

There is absolutely no basis for the average orthodontic fee. None. How did this fee come about? Way back when, orthodontists had open contracts which were essentially pay as you go for the consumer. There wasn’t much impetus for efficiency seeing that the longer you treated, the more you got paid. Once fixed contracts came into use, an average fee was set based on the earlier cases and that fee has escalated incrementally over the past 60 years. We’d also add that many consultants have been advising clients to raise fees annually since the 1980’s and we will admit that we were advocates for maintaining above average fees for many years.

In defense of our fees, we orthodontists tend to talk about how valuable our time is and how high our overhead is but if we were honest we would see that we have adopted this average fee as the way things are (we’d bet 85% of us are within 5500 +/- 1000 dollars) and we’ve set up our offices, staffing, schedule, overhead, and lifestyle expectations based on this “reality”. There is not a thing in the world wrong with this. As a business owner you can charge whatever you like for your services. We only bring this up to make it clear that we might need to revisit the fees we have traditionally charged rather than viewing them as sacrosanct. If we can get out of the mindset that anything lower than a “normal” fee is bad then that frees us to consider another way.

Instead of determining fees by looking at what other orthodontists are doing, we suggest setting a fee based on what consumers will find attractive and then modulating the service we offer to match the fee. This is a much better way to setup and run a business. And make no mistake, we orthodontists who own a practice are running a business – or we should be.

In the process of Burris setting up a new office in Central Florida and implementing all we have learned over the last couple decades, it’s been interesting to examine what is actually needed to run an owner/operator, single location orthodontic practice versus what we orthodontists traditionally think we need. If you really examine this difference, a 3000-dollar fee in a physical plant and business model set up for it can be more profitable than a 5500-dollar fee in a traditional setting! Burris plans on sharing his P&L here on OrthoPundit as the office progresses so we can all see whether or not our theories bear out.

Let’s go through a few examples of what we are talking about here (this is not an all-inclusive list):

  • Bracket cost – Burris buys most of his appliances/supplies from and pays pennies while many orthodontists pay dollars per bracket. Same goes for wires, elastics and accessories. Why are you paying what you pay for your appliances? Does the consumer recognize an orthodontic brand name like they recognize a designer clothes brand? We think not.
  • Invisalign utilization – Burris is going to charge even less for Invisalign than for braces but deliver Invisalign in a manner that is low stress on the practice while satisfying the wants and needs of clients. If a normal store can sell something and make an 80-100 percent profit with very little effort then they are well satisfied. What makes Invisalign different? Generally orthodontists don’t understand that consumers want and are generally very satisfied with straighter… And, as a bonus, since Invisalign offers 5 years of free aligners then you can contact these patients at year 4 and offer to retreat any relapse they have very affordably (and with zero lab cost) to the delight of the patient and the profitability of your practice.
  • Marketing cost – At a 3000-dollar price point, orthodontics will sell itself. In this scenario, the doctor can stick to smart utilization of targeted, internet marketing to get plenty of new consumers while saving tons of money. These days many orthodontic enterprises are spending almost 5% of revenue on marketing expenses. At a 60% overhead how many consumers do you have to treat to net enough to cover your current marketing budget?
  • Pandering to dentists – Again, at this price point the orthodontist will not suffer the shortage of new patients that a 5500-dollar practice often does and thus will not need to spend the time, effort and money traditionally expended on potential and existing referring general dentists. The savings of doctor time here could be even more valuable than the dollar savings.
  • Giveaways, contests, patient appreciation parties and the like – None of this will be necessary in the 3000-dollar practice saving an incredible amount of money, time and effort. Swag does not contribute to margin in a positive way.
  • Office square footage – The physical plant of the 3000-dollar office will be radically different. Though nice, warm and friendly, you’ll notice that there are no TC rooms in this office. With a 3000-dollar flat fee and one financing option there is no need for an hour-long TC driven sales process. People know what they want before they get to your office, the chairside assistants can easily explain and help the consumer fill out the paperwork and your conversion rate will be higher because of the affordability, transparency and simplicity. There really isn’t any basis for the TC driven sales process anyway (other than that’s what we have always done and that’s what consultants get paid to teach us) and other comparably priced, elective products or services don’t do sales that way. Think of going to a jewelry store to spend a few grand and being forced to go through a tour and an hour-long consultation… Depending on volume (and it should be high) the 3000-dollar office may want to keep a financial coordinator positon to assist the chairside assistants and do recall/observation but this position will look nothing like the traditional TC.
  • TC salary – Many 5500-dollar offices have multiple TCs and financial coordinators. The need for these positions will be much reduced in the 3000-dollar office and that means a great deal of savings to the practice with no loss of efficiency.
  • CBCT cost – Orthodontists don’t need an in office CBCT. Period. If you need a 3D scan for the occasional case then ask the oral surgeon you refer to for one. 150 grand is a lot of money to spend just to be cool. The average patient does not care one bit.
  • Several things the 3000-dollar office will have to do well
    1. Treatment efficiency and case selection – the 3000-dollar office must run on time, have simple/effective mechanics, finish patients on time (no overtime patients) and avoid the 5% of cases that cause 98% of problems. Burris won’t be doing impacted canine cases that require exposure and ligation, he won’t’ be using Class II correctors and he won’t be extracting teeth to elicit A-P correction. He will refer these more difficult cases to local orthodontists telling these patients that they should expect to pay more because of their outlier status. Traditionally orthodontists have charged more for easier cases and less for harder cases to normalize pricing across the board but this custom will be less viable in the future. The 3000-dollar practice will be the living embodiment of the Straighter Philosophy and Burris will only treat cases that he can finish in 12 months. Compliant consumers will get a good deal of A-P correction using elastics over the course of treatment and Burris plans to do orthognathic cases as they are generally straightforward but non-compliant consumers will be asked to leave the practice and cases that will take more than a year of treatment will be referred instead of started. Of course experience is the essence of orthodontic efficiency and what an orthodontists can do in 12 months differs greatly based on experience and ability so each doctor will have to determine these limitations for themselves. As an example of what can be done even without the benefit of case selection, many of the cases Ackerman treats in a hospital setting for 4900 dollars are difficult outliers yet he does so efficiently and profitably. Given the right systems and clinical efficiency there is no reason any orthodontic enterprise should not be profitable as long as the new customer flow is not compromised by artificial barriers or high price.
    2. Patients per chair per day – The “industry standard” is 12-14 but in the 3000-dollar office the team will need to see 18-22 patients per chair per day in an 8+ chair office. This is easily accomplished if you do the math. This kind of efficiency is only possible with a well crafted schedule template but when done properly it greatly reduces the single most expensive part of running an orthodontic enterprise – staff cost. At speed the 3000-dollar orthodontic office can expect their staff cost to be under 15% and even approach 10% of gross collections.
    3. Same day starts – This is not an option but a way of life in the 3000-dollar office. Both arches will be bracketed at the same time. To do otherwise costs additional bond appointments that a high volume practice can ill afford.
    4. Long appointment intervals – 8 weeks at minimum. This is better for patients anyway given the technology we use, applying light forces over a long time and alleviating the inconvenience of having appointments more often.
    5. Same day debond – When a patient is ready to get the braces off then they come off. No need to schedule and burn up additional, long appointment slots.
    6. No steel ties – Steel ties are dumb, take too long to tie, patients hate them, it takes a great deal of effort to train staff members to use them, they are no better than elastic ligatures and a large lumen eyelet works far better when trying to de-rotate a tooth or bring an ectopic tooth into the arch.

What the owner of a 3000-dollar office must give up:

  • The pride of tackling difficult cases – The owner of a 3000-dollar office must avoid the 5% of cases that eat up an incredible amount of time and resources as their office is just not set up to handle them. We orthodontists tend to focus on the outliers but this is not possible in this office setting.
  • Pride (again) – The owner must put the needs of the many above the needs of the few and put their pride aside to stick to the business model that will provide affordable orthodontics for the majority of Americans. This will be difficult as we orthodontists are like power lifters and we believe that the harder the cases we do the more awesome we are. This is not true but we believe it nonetheless.
  • Prestige and peer recognition (pride a third time) – We orthodontists love nothing more than to be popular and beloved by our peers. This is a big part of the reason our profession is in the state we find ourselves… The owner of the 3000-dollar practice cannot afford such luxuries.

What the owner of a 3000-dollar office gains:

  • A never ending supply of new patients.
  • Security and sustainability for the practice.
  • Schedule freedom – At this price point the orthodontist can take off some of the most popular times of the year (when our kids are out of school) and spend time with our families because consumers are coming for the price.
  • Massive profitability – Not on a per patient basis but in treating more patients because of a more affordable and attractive fee.
  • The satisfaction of knowing that you are making orthodontics affordable to the majority of Americans.
  • Dealing with a clientele that appreciates you and what you do for them.

Our favorite customer is the single mom working her tail off to provide for her kids! This may sound like a random statement but who better encompasses the argument for enhanced access to care and who more deserves our services for her kids? There are millions of these moms in this country and they are generally very grateful for the opportunity to provide orthodontic care for their kids while not blowing the family budget. Of course we will treat any and all who want our services in the 3000-dollar office (except the outliers and the most difficult cases) but we can’t help having our favorites. The point of all this being that orthodontic care is currently available to such a small percentage of the population that we consider this the Golden Age of Orthodontics for owner/operators who can overcome our orthodontic groupthink and see the opportunity right in front of us. A lower fee doesn’t mean doom and gloom. To the contrary, it means massive growth and profitability for anyone willing to put in the work. Will you?

** The NUMBER ONE problem in the modern orthodontic enterprise is a lack of new customers and the biggest driver of this problem is price. IF your office has plenty of patients who are willing to pay the fees you are charging and if they feel they are getting value then, by all means, continue to charge what the market will support in your area. However, even if you find yourself in this situation today, please understand that unless you are a true boutique then you’ll likely be in the same boat as most orthodontists soon. Increasing efficiency and cutting costs will not hurt you no matter where you are in the market and that is what we are advocating here most of all.

**3000 dollars is the number we have chosen to represent the average fee in the future. As we have mentioned before it may be higher or lower in your market depending on where you live but 3000 is a highly educated guess. What is the right number for you? The number that elicits a WOW! from your customer base and causes the results we’ve described above.

29 thoughts on “Why 3000 Is More Than 5500

  1. Getting people in the door is the name of the game. Definitely an interesting model if one is able to handle the clinical volume efficiently!

  2. No doubt. One must hone the skills and mindset to operate differently!

  3. looking forward to seeing the details of your plan. my thinking is similar to yours but i think you could cut expenses even more by only treating with removable appliances and reduce staff by 1/2 and cut down on the size of your office by 1/2. then see patients every 8-20 weeks and do more follow up with remote monitoring. ask your next few patients would they rather come into your office to be “checked” or have you use technology to check in with you ?

  4. the price is not a major reason, why folks cant afford ortho tx. It is all about financing. Car industry is doing it all the time with those monthly leases and no one cares about the total car cost. I think people who cant afford 4k price would not be able to afford 3 or 2 K prices, period. As as marketing tool against competition, may be it is a point but again, you would need to provide a good service anyway and good services will cost good money. In addition, doctor cost is increasing every year due to GPs hiring orthos like there is no tomorrow. Unless Burris plans to work there by himself, the cost of labor will be high. Doctor cost can easily run 1200 per day, plus certified experienced assistants, office manager overseeing the operation, still need collection and billing, it wont be cheap, Thanks for the article. Well written.

  5. Good points. Excellent financing is the reason many owner operators can still charge 5-7 k for orthodontics but financing will not trump price long term. We have seen a great deal of downward price pressure for the last two years and the economy is strong. What will it look like if the economy slows. I don’t agree that going from 5 to 4 or from 4 to 3 k is will not make a difference to the average American but we will see. Your point about me working the office myself is well made. I thought I was clear by saying it would take an owner/operator to make his model work but apparently I was not so thanks for pointing that out. I will work this office myself and it will be the only one I have! A true lifestyle pracrice that I’ll work 3 days a week, 10 months a year. I think it would be difficult for an associate to be able to make this model successful for lots of reasons. Thanks for the insight.

  6. In NYC area (Where I’m from) Orthodontists routinely charge $2500-3500/case start to finish w/ retainers. Invisalign goes for around $4K. I would not say that this has increased the # of patients in the long term. 5-6 years ago, the lower price point was HUGE as you were the only one doing it. Today, everyone has the same price point. I’m not saying that we should raise fees, the truth is that there is incredible downward pressure on our fees and we have to adapt and innovate where possible to stay competitive.

  7. I’ve seen GPs use the exact model you are describing in order to get more ortho patients. They reduce the fee, take most of the easy cases, and tend to get tons of patients doing it.

  8. I’d be interested to see one doing signicanr volume. Thanks for sharing.

  9. Fair enough. The price point will be different in different areas for sure and the landscape will constantly change. Thanks for the input.

  10. Good points Ben. It will work, no questions here. Could it be implemented without you being there? That is the real question. I do agree that the price will be coming down in the near future due to competition. Another point, I did not mention. When you choose “easy” (non exo, non surgical, etc) you will compete against GPs, SDC, 6 months smiles, 3 months smiles, “fast braces” and some other circuses from out there. They only can engage those “simple” Class I cases. I know that we see them less and less nowadays. We do see a lot of difficult staff those. In that 3K model, I dont think you would be able to afford to refer those cases out.

  11. It will take an owner operator to make this work I think – I’ll be the only one seeing ortho patients in my new office. I can do a heck of a lot in 12 months so I won’t turn down near as many as you might think but I will refer impacted canines that need E and L, missing lateral cases where we aren’t closing space and any AP cases that won’t be surgically corrected and the patient wants total resolution ( I won’t ext for AP correction and I won’t do any kind of class II corrector). It will take a great deal of clinical judgment and experience to know when to hold and know when to fold. I’ve got that but I don’t think I could have an associate do the work.
    As to competing with GPS or STO I don’t see it like that. I’ll be offering a great service in a great office with great results for the majority of ortho cases for 3000 bucks. I know you don’t think this way but most orthodontists don’t think that can be done. Consumers who are not an outlier/very difficult case will not really be able to tell the difference between my office and any other ortho office. It will be easier to demonstrate than talk about I believe. Come visit me once I have it up and going!

  12. RE: 3k vs 5.5k price point Orthopundit article: Questions for Ben-8.28.17

    Thanks again for this article Ben. Seems to me this all makes sense and I have been wondering about following a similar strategy all along.

    I think the only caveat is that if we are limiting this low price point treatment to straightforward cases only (Class I and mild to moderate Class II crowded patients), it means we will still have a 2 way door for many new patient exams meaning you will still have a low “raw” conversion rate and need an even bigger new patient funnel. Or do you have a script or way of screening some out on the new patient phone call?

    So my big question is first how do we inexpensively use internet targeted marketing mentioned in your article to get these folks to our door in large numbers and secondly how do we get them to understand that we can only offer this price if they same day start and are compliant?

    Marketing ideas and scripts for this would be greatly appreciated!

    My third burning question is if you have any suggested strategic scripts for turning down/referring out the more difficult cases that don’t meet your case criteria/parameters?

    Lastly, what is your script for terminating the $3K patient that turns non-compliant mid-treatment?

    Also, am I correct in assuming we are talking mostly about patients without insurance or Medicaid in this article or does that not even matter?

    Thank you again for leading the charge!
    Steve Kineret
    PS. Looking forward to seeing you at the MKS forum in October!

  13. Great questions. We will cover all of that in detail in our 2 day implementation course and the book.

  14. Love the concept.I have a few questions: Are there legal problems with an orthodontist turning patients away? Is that allowed?
    How do you handle a single mom whose kid has an impacted canine?

  15. No legal problems. Orthodontists can turn away patients based on difficulty and do it all the time. Ask Ackerman how many cases he gets referred to him at Children’s Hospital. The scripting is easy and we cover it in the course.

  16. Ben, Why not treat Class 2 patients also (without Class 2 correctors- only elastics) as long as patient is fully informed that treatment is for alignment/cosmetic purposes only…not bite correction. I do this routinely with adults in 6-8mos. Are we still at risk even if fully informed and signed consent. GP’s do this all the time….I can do it a lot better.

  17. I plan to do exactly that. they will get great AP correction if they are compliant but we will only do it for 12 months or so (less if they are not compliant) and no class II correctors and no extractions to address AP issues either. Thanks for asking – I didn’t do a good job of clarifying this point obviously!!

  18. I would love to see your Consent Form if it is over and above the standard AAO form. Mine is totally separate of the AAO form….it goes into much more detail and nuance and covers all those (as many as my 30 years of experience can think of) “unreasonable expectations” that most patients have.

  19. Ben, LOVE the article. Do you know of any 3000 dollar practices models in existence? Do you already see patients in your new practice? Do you go through any sort of on-line screening process before patients walk through your door (such as facial/intraoral photos e-mailed to you by patients)? How about records? Is ceph really necessary for this type of practice? What percentage of Invisalign cases are you projecting to see in comparison with braces?
    Thank you

  20. I’m not seeing patients yet. I’m hoping to open in February or March but you know how these things go! We will utilize much of what you mention. The percentage of invisalign question is a good one. I don’t have an answer yet but have my suspicions. However people I respect disagree so we will wait and see what happens there. Thanks for taking the time to comment.

  21. Why not skip using brackets at all? All the cases you mention that you will treat can be done with aligners only. Less staff needed, less sos- appointments, less stuff lying around etc…add in teledentistry and you have a sdc/ office hybrid with the benefit of applying IPR and Attachments when needed.

  22. I believe you have a great model for the GP doing orthodontics. Treat the easy stuff and send out the challenging “outliers” that need someone with more training to treat. If we’re only interested in “giving patients what they want” specialty training isn’t necessary. Aligners can handle it.
    Skip the residency – get an MBA instead. It’s a lot cheaper and easier to get into.

  23. Thanks for your thoughts but I don’t think you quite grasp the concept on multiple levels. The fact that you don’t think an orthodontist’s job is to give people what they want even though what we do is almost totally elective and noninvasive is interesting. I do agree that residency is a waste of money and counterproductive for the most part because of all the stupid things it beats in our heads and the very limited hands on training it affords and how little it prepares people for practice. Such is life.

  24. I would agree our profession has changed from giving our patients what they need to giving them what they want. However, that doesn’t relinquish us from the responsibility to educate them about their problems and what can be done to address them. After all, that’s what Dr means: “to teach”. I also feel bad that you believe your residency was a waste of time. I was fortunate enough to attend one that prepared me to go into practice feeling confident I could treat the “outliers” well.
    The reality is our patients really only know if we get their front teeth straight. I believe it’s ethics, not ego, that drives me to get their occlusion corrected. You’re right, we can all get the teeth straight in a year, it’s getting the occlusion right that takes the extra time. Are you going to take your children’s, or your spouses, braces off because it’s been 12 months?

  25. Again it’s obvious you don’t follow the model on any number of levels and you’re projecting your beliefs on me. I’m an excellent orthodontist and I get excellent results and do so very quickly because I’m extremely experienced. I have treated plenty of outliers and choose not to any longer. I take it you never send any craniofacial, behavioral or cleft cases out of your office to Children’s Hospital or elsewhere? If so that’s your choice but that also makes you an outlier among orthodontists. What doesn’t make you an outlier is your claim that you finish every case with perfect occlusion. Any time you’re ready I’m happy to have you come visit my office and we will look at every case that comes in and you can critique and photograph them… then I’ll show up at your office on some random day you’re seeing patients and do the same. Let me know your address and we will make a plan to compare our median cases and then discuss “quality”. Guys like you crack me up. Keep living in your fantasy world or let’s stop trading euphemisms and compare what matters – what really happens in the office day in and day out.

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