More Marketing Is Seldom The Solution To Bad Economic Times

An article dated December 1st in the L.A. Times entitled:  "Dentists Turn To Marketing After Getting The Brush-Off From Patients" details how dentists have struggled to adapt to the new, less prosperous, dental environment.  In the article dentists are said to be spending more money on marketing, consultants, and seeking strategies that will return them to pre-meltdown profits.  As a dental consultant I was surprised how accurate the article really was in light of it coming from outside the industry.  He concludes by saying that patients have notably reduced their visits to the dentists, pointing out that patients are now saying "it's just a cleaning".  This should be a wakeup call for all of us.  It might be "just a cleaning" to the patient, but to the dental industry it's a matter of life and death.  The lost restorative dentistry resulting from missed or non existent hygiene visits is potentially devastating.

What does it mean that dentists are turning to marketing, or to consultants?  I'm always amazed that some doctors believe that their real problem is that their not spending enough on marketing.  While it's true that some of the newer doctors or larger multi doctor offices are forced to commit a higher percentage of their gross to aggressive marketing, the normal solo operator affected by our current economic situation, will find an increased marketing budget to be a big disappointment.  Is the real problem in dentistry the fact that all at once, patients just forgot about us?  Did the economic downturn effect their ability to remember how great our office experience really is?  Think about it, if our super satisfied patients are fading away because of our new economic reality, will advertising patients who have never met us like us any better?  The forces driving our best patients away are the same ones that will make paid advertising that much more challenging.

When an office is really under the gun to advertise new patients into an office, one of the first things they learn is that advertising patients are more challenging to work with.  Add to this idea that a slew of marketing patients are going to start filling the few ops you already have with visits that produce restorative dentistry about half the time.  I don't mention these things prove dental marketing a bad idea, just to point out that fixing our current state of economic-driven practice erosion with marginally cost effective marketing patients is going to be a disappointment for most docs who go this route.

So, what is the answer to current economic conditions?  This situation is like draining a lake, you find all sorts of things that probably don't really belong there.  In dentistry, you drain the economy and you find prices, policies and practices that really were supported by a booming economy or generous insurance benefits. Let me give you a great example of some of the things we find when we tear a practice apart looking for the cause of lost production.  

"Piling On".  When you tell a patient that a cleaning is $97, this done in an effort to get them in the door, then start piling on lots of small charges.  I'm talking about everything from rinses to periodic exams, to an arm load of removable appliances.  Much of this pile-on selling is commissioned, so no patient is left undamaged.  Commission seeking hygienist are very thorough, every patient is pitched for ad-ons.  Not all hygienist fall into this category but it's a good idea to recheck and make sure I didn't just describe your office.

Not only is it interesting to see how many $97 cleanings turn out to cost $250, but to find that doctors themselves don't accept the reality of their own fees.  When asked directly what a new patient will pay on their first visit, the average dentists will quote number that is far below the amount the patient will be asked to pay.  Typically, the conversation goes like this, "So, how much does a patient pay on their first visit"?  The doctor responds by listing all their charges, avoiding the total, because they know it will sound too high.  In other words, they won't even admit to themselves what their patients are being asked to pay.  This may have worked when everyone's house doubled in price every 4 years.  Today, it's the formula for slowly dissolving your practice, and no amount of marketing is going to fix it.  Some doctors fear backing off on the "pile on" strategy for fear they'll see their bottom line reduced.  In the short run this may indeed be the case.  In the long run...well, there won't be a long run for doctors who believe that secretly piling on fees for itemized services will fool the patients into continuing pay more for treatment than feels comfortable.   

So, am I telling you to cut your fees?  Personally, I believe that's the last place to go when it comes to making major practice changes.  I do think it's time to look at what we're selling to patients.  For those patients who fear they may not have a job next week, lets make sure they have all of their essential restorative dental needs met before we systematically shake them down for everything a patient could possibly need done to their mouths.  Of course you don't want to overlook or under play their true clinical needs, but stay with a treatment sequence that fits each patients financial capabilities.  Be very aware of who's pushing what in the practice.  Too many doctors are afraid to weigh in when a hygienist is hard-closing every patient on big soft tissue cases.  The doctor fears that he/she will appear weak in the war on gum decease.  It's almost as if the doctor stands by and watches his or her practice being destroyed by a morally superior hygienist.  

Isn't it true that most of us fear the law of unintended consequences?  If you make the practice more patient-friendly and more in tune with the current economy, will it ultimately be your undoing?  The answer to that question is simply NO, staying on the course that's hollowing out your practice will be your undoing.  You don't have to make all these changes overnight, just start looking at the practice from the standpoint of how you can make the treatment more affordable, more in line with the patient's priorities, and less from the viewpoint of "what else can we sell these people".  No doubt, in the end it means we're going to have to see more patients and make them even happier than they are now, no easy job, but that's the challenge of our times, not simply buying more Facebook ads.  

Team Selling In The Dental Practice

At a recent Whitehall Team Training held here in Arizona, a survey of the group revealed that in 80% of Whitehall offices the staff make the treatment plan presentations.  I might add that these are among the most successful practices in the country and most of them are heavily manned with associate doctors. 

So why are staff so successful at closing cases that even owner doctors struggle with?  Actually, there are several reasons:

1. The personality of the owner doctor can be an impediment to his or her own success with treatment plan presentations.  The owner doctor may be so non assertive that patients are quickly confused by his natural gift for draining all sense of urgency from the presentation.  On the other hand he may be too dominant, leaving patients feel like they’ve been bullied into unwanted treatment.

2. The staff’s natural patient perspective.  So often, a dentist has so much clinical training that she’s unable to get down to the patients simple level of clinical understanding.  The staff however, know exactly how a patient thinks and feels when expensive dental treatment has been recommended. 

3. The patient’s perception of ulterior motives.  Most of you reading this article already know that patients trust staff when it comes to presenting expensive or unexpected treatment.  As soon as the doctor walks out of the treatment plan presentation the typical patient will turn to the assistant and ask them if they really need all that treatment.  That’s right, you already had your suspicions that staff have the edge where this is concerned.

4. Assistants have far more time to spend helping a patient get up to speed.  To often, the doctor’s body language communicates to the patient that he needs to be elsewhere ASAP.  This leaves the patient feeling like they can’t air their doubts.  This can only lead to one outcome:  “I want to go home and think this over”, or “yes, I want the treatment but I need to check my schedule and call you back”.  None of these responses end well.

5. Patients feel more comfortable asking. what they fear will be perceived as dumb questions, to a staff person as opposed to the doctor.  Unfortunately, we’ve found that it’s the unasked “dumb question” that leaves a patient with overwhelming doubt about the treatment. 

We’ve found that a “team selling” approach is the end-all answer to improving case acceptance.  This means that every staff person who comes in contact with the patient will do their part to infuse credibility and urgency into every presentation.  Usually it’s what’s said before the doctor enters the room that imparts urgency, and remember, without urgency you’re not presenting a treatment plan, you’re just having a nice discussion about dentistry.

Cube Farm Dentistry

If you ever get the chance to visit the offices of a large corporation you will probably be quick to notice the size of the cube farms occupied by an army of bored looking employees.  And why shouldn't they be bored, there are hundreds of them in tiny cubicles entering data or answering help lines.  If you're from the dental world and you are exposed to this scene from a dreary forced labor camp, the first thing that comes to mind is how do they get all of these people to be fully productive.  The answer to this question is usually that they don't get them to maximize their performance, they just pay them accordingly.

I mention this phenomenon because too many dental offices have outgrown their ability to supervise their ever growing contingent of employees.  No, there are no cube farms in dentistry but you can experience the same frustration corporate supervisors face when they're charged with getting under supervised employees to perform at or near their potential.  In dentistry, staff's performance falls along a continuum ranging from lackluster, near stupor-like zombies, all the way to highly motivated, compassionate employees with a laser focus on customer service.  Unfortunately, they all want top pay.    If you're normal, you're probably so busy triaging patients that you don't really know where you're staff fall along this continuum.  You may not, but I'll bet your patients know where they fall.

What are the symptoms of an under supervised dental office?

1st:  Inability to implement new systems.  You return from a practice building meeting with a three ring binder filled with great ideas, only to find that staff humor your enthusiasm, but put off implementation until you've lost your zeal for the new programs.

2nd:  Barely disguised hostility toward other team members.  The office runs more like a sand lot football game with no referees.  New staff are especially vulnerable to the natural abuse veteran staff are likely to dish out to the uninitiated.  It's not unusual for a sorority like environment to set in with an unendurable hazing in store for the new arrivals.

3rd:  Staff pick and choose which patients they will connect with.  In the under supervised office, staff will go out of their way for people they would normally like if they met them outside of the office.  Those who remind them of someone who has previously mistreated them, are treated with barely disguised contempt.  This isn't an indication of how corrupt a staff person is, it's simply the natural outcome of the unprofessional environment that arrises when no one's in charge.

4th:  Staff defaulting to a reduced work load.  This is actually worse than it sounds.  A reduced work load in this case refers to staff consciously or unconsciously failing to do their part to push for daily production.  This can be as simple as front desk staff failing to check with the clinical staff to determine if an emergency or same-day opportunity can be accommodated.

5th:  Staff mistakenly believing that they're super stars:  In the under managed offices I've visited I'm always impressed at how many people who I would quickly identify as needing to be fired, are instead, at the head of the line of those demanding higher pay.  In their supervisory vacuum, they've reinvented themselves as irreplaceable workhorses, when in fact, they're anything but.

No, dentists are not cube farmers, but their inability to maximize team productivity can easily match that of a sprawling nest of under worked corporate employees.  So, what's the answer to this problem?  Simply this, appoint a member of your staff as the leader of the practice or of a department.  Yes, I know, you don't have a single person on staff with a management background.  Not to worry, the best leaders in Whitehall have little or no management background.  In the majority of offices I've encountered, they're better off with poor leaders than having no one in charge.  In the leadership vacuum of dentistry, a nasty feral community grows up to eventually block all hopes of practice growth.

The Terrible Cost of An Under Trained Team

From the few times that I have actually gone fishing I learned one valuable trick for hooking extremely large fish.  It was this simple, just wrap your line around the trolling motor several times after casting your bait into a likely big-fish hiding place.  That's right, just make sure that if a large fish does grab your bait that you're not ready to reel him in.  I know that sounds strange but I've found that this technique works when nothing else will.

Of course you realize that I'm sort of making a joke here, but the technique I'm describing actually works.  The downside is that even though you finally did lure one of the big ones to your bait, there's no way you'll ever get the line unwrapped from the motor quick enough to set the hook and land the fish.  In other words, the lack of preparation seems to attract opportunity that will ultimately mock you.

Every week that passes I'm more aware of practices that aren't ready to deal with the occasional large case that shows up in the practice. The title of this article is "The Terrible Cost of An Under Trained Team", well here's one of the most common points where the practice is punished for lack of preparation.

Most doctors don't even know this is going on in the office.  While they're in the back, head down, drilling, filling and crowning for all they're worth, the staff assigned to make financial arrangements are consistently finding that treatment plans greater then one or two thousand dollars always result in patients deciding to return for treatment when their finances improve.  In the fully trained office, the financial arranger is able to consistently collect on five figure treatment plans.  Most doctors don't really know how to respond to a staff person that routinely finds that none of the big-case patients has the money for treatment.

My point in this article is to emphasis the cost of this lack of preparation. Think of how many doctors set off in search of sedation riches only find that all the phobics are broke.  On the other hand, there are offices where every phobic that can overcome their fear of treatment is able to somehow come up with the money for needed treatment, the staff's training and commitment making the difference.

As we struggle to cope with the ever mounting discounts demanded by insurance companies, many doctors are fearful that there will literally be no profit whatsoever to take home if this unrelenting trend continues.  The office that can fully maximize its larger case opportunities will have a greater profit cushion to throw against the 30 - 40% in-plan discounts that currently stalk the industry.

I've found that each staff person has their own individual financial arrangement qualifications.  Some are good up to $1,500 (quite common) and a few can go all the way past $25,000 (very rare).  As you read this you may be thinking that your practice gets access to larger cases so seldom that there's really no point in pushing a staff person to learn these skills.  I disagree.  For years Whitehall's emphasis has been on consumerism and seeing that no one is oversold.  While that's true, were finding that the handful of large cases that actually could change your life are usually mismanaged at the front desk by the financial arranger.  All they have to tell you is that yes, the patient wants the care agreed to with the doctor, but no, they don't have the money to pay for it.

While there are a few offices that actually do have someone trained and motivated to collect on larger treatment plans, this skill usually resides in just one person.  As soon as the office gets busy enough to occupy this one great collector, the big case will float up out of the back, only to land with the new person who believes that in this economy, no one can afford five figure treatment plans.

If a patient really does want the care, there is a way for them to pay for it.  Maybe you don't really believe that, but you'd better hope your financial arranger does, because there lies the profit that could save your practice from the ravages of deeply discounted insurance plans.  I'm not talking about pushing large cases on reluctant patients, I'm talking about knowing the techniques for making F.A.s that could add $2,000 - $5,000 per week to your bottom line.  If you're a bit non assertive and you hesitate to show willing patients what they really need, and if that same lack of assertiveness causes you to accept your staff's claim that patients can't afford the care they agreed to in the operatory, then you're headed for a very thin paycheck.

In that sense, practice is a lot like fishing.  Quit wrapping the treatment plan around the weak F.A. skills of your front desk.  Yes, it causes the big cases to show up in the office, but you never get to treat them.  A very costly mistake.

File Cabinet Millionaires

You've told patients what they need, some of them even agreed to schedule treatment when they were in the chair, but at the end of the day only a fraction of what you've recommended actually gets scheduled.  I think the term that's often used is "File Cabinet Millionaire".  In other words, if everyone did what you recommended you'd have a awesome dental practice filled with perfect smiles.

The impact of under developed cases on dental practice is staggering.  Everything from poor profitability to low doctor self esteem are on the table.  So what's at the heart of this problem?  Actually there are several underlying issues to look at.

First:  Overwhelmed Patients.

Although we often to think of our patients as having low dental IQs, I doubt we would do any better if we were in the same position.  What if you weren't a dentist and found yourself in the chair seeking treatment for a specific tooth, only to be told that you needed thousands of dollars of unanticipated treatment?  I suspect you'd need to go home and think it over (another way of saying you're going to go home of try to forget this ever happened).

I fear that too few doctors or their assistants know where treatment is really sold.  Most believe that it's all about the case presentation or the "close".  Nothing could be farther from the truth.  A common practice is for a doctor to repress a patient's questions during their examination.  This is understandable because the doctor often has another partially treated patient in the next op, and at least one patient waiting to be checked in the hygiene department.  While this is understandable, in the end the overwhelmed patient always has the same response to a perfectly worded treatment plan presentation:  "I want to think it over".  That's another way of saying "Game Over".

So, where IS the treatment really sold, if not during the treatment plan presentation?  Forget where the treatment is sold and focus on where it's bought, that is, where the patient buys it.  The answer to this question is that it's bought during the examination.  When you're examining a patient and you find something, the patient will want to ask questions about what you've found.  A doctor's intuitive response is tell the patient to be patient and wait for the whole picture.  When the patient asks about what you've found and you put off your answer until a time when you can bundle the entire package into an overwhelming, unexpected list of needed dentistry, the outcome can't be anything but "I want to go home and think it over".

Second: Lack of Urgency

While this is often a factor of a doctor's personality, it also comes about as patients are expected to come into our offices already knowing a great deal about their teeth.  Without a smooth and well scripted interaction between staff and patients, most of what a doctor tells patients in the case presentation is not fully understood.

Telling a patient that they have an unexpected problem with a single tooth and that treatment is needed, is usually well received, especially if they are a patient of record.  If the patient is new to the practice and you announce that there are number of teeth in need of expensive treatment, an unprepared patient will naturally flee the office.

Once you've told the patient that unexpected treatment is needed for several teeth, questions about severity and consequences arise in the patients mind.  Add to this a doctor that softens the presentation with waffle words like "you may want to eventually" or "this is a tooth that could cause you problems down the road".  Add these together, waffle words with multiple, unexpected treatments and you've got the perfect formula for patient overwhelm.

Third:  Lack of Team Support

If your assistants fail to portray urgency or value, and your front office staff handle financial arrangements like they're collecting money for a traffic ticket (meaning they don't have to do any more selling), the odds of the patient agreeing to treatment or showing up for their next appointment are weak at best.

While these three points are conceptual, they should help you zero in on aspects of the practice that are contributing to your under developed cases.

I Don't Have Enough New Patients

You've been in practice 18 years and you're pretty clear that most patients are very impressed with both your dentistry and the TLC factor of your team's patient interaction.  You're a solo practitioner so there's no other doctor in the office to undo the great experience you're delivering to your patients.  Your staff are simply the finest you've ever worked with.  So where are the new patients?

You know that the national average for monthly new patients in the dental office is 22 but that's for the average clinic delivering the average service.  You know you're better than that, so why aren't new patients breaking down the door?

That's a great question and one I probably hear about once per week. What is it in this picture that many doctors are missing?  We should look a little closer at the monthly referrals before we jump to any conclusions.

How many patient-to-patient referrals should a dentist be getting each month and how many are possible?  At this moment Whitehall is coaching doctors who average upwards to 200 referral patients each month.  The current all time world referral record is held by a doctor in the Northwestern United States with just over 300 referrals per month.

Granted, these offices have numerous associates so that has to be taken into consideration. Personally I think an office that can generate these amazing monthly referrals numbers is accomplishing the near-impossible.  When you have just one owner doctor ready to impress and schmooze it's not so hard to hit these great monthly referral numbers.  When you have a chaotic tangle of staff and associates bouncing around a monster office and still achieve referral numbers north of 200 per month, you're in a class by yourself.

So how many referrals should you be averaging?  From decades of personal experience coaching I have to say that my number is 40 per month, and that's per practitioner.  If you have 3 doctors under the roof, you should be shooting for 120 direct patient-to-patient referrals per month.

So many doctors mistakenly think that a shortage of new patients indicates a marketing deficiency.  In other words, too few new patient simply means that not enough money was spent on marketing.  To answer this best think in terms of two stages of new patient shortages and responses (like marketing).

First, for the solo practitioner, his or her schedule can and usually should be filled with patients referred by other patients, in other words, marketing is often optional for these doctors.  The second stage involves filling an associate doctor.  This is where the marketing budget comes into question.  When a doctor calls to ask how much he or she should be ready to spend to flood their associate doctor with new patients, they, like me, wince at my answer.

The right number is 7% of your gross monthly revenue to be spent on hard hitting, high impact marketing pieces.  At Whitehall we don't have a doctor grossing in the $500,000 per month range who is spending less than that number.

Let's start with the referral side and then discuss paid advertising.  First referrals, they come from several sources:

1.  Insurance companies send them to you because you've signed up for their plan.  The discount they insist on often makes marketing look cheap by comparison.

2.  Staff working for incentives, watch for patients with family members or professed friends that aren't a patient of the practice.  Once identified, they make a direct request for the patient to send in the friend or relative.  Often there's a small incentive tied to this action in an effort to keep the staff person in the hunt.

3.  Inspiring patients with full-on knock your socks off approach to wow the patient into telling and selling their friends on you.  This one is of course, the most difficult because you have to give the practice a complete overhaul to see that the patient never encounters an unpleasant staff member or is left waiting 30 minutes for the doctor to check them so they can leave.

No doubt, number three is the gold standard, it's the one that tests your control of the practice (staff).  This subject was introduced in an earlier blog entitled "The Biggest Problem In Dentistry".  If you can only make suggestions to your staff as opposed to giving commands, it's very unlikely they're going to put their full focus on impressing your patients to the point they'd naturally tell everyone they meet about you.

If you are really impressing patients and they're not referring others to your office, you're just kidding yourself, you're NOT impressing them.  Oh, maybe in some ways but not in the ways that count.  Maybe you do have someone running up to new patients as the enter the practice for the first time, putting a water bottle in their hands and fussing over them in other small personal ways. All's well until they meet the hygienist on commission who hammers them for 4 quads, a sonic spinning toothbrush and a ticket to her own multilevel sales meeting.

Sure, you're doing most things right but unfortunately, it only takes one predictably unpleasant encounter in the office to insure that all your schmoozing and fussing over the patient goes up in smoke.  Like I say, inspiring patients to refer indicates highest evolution of customer services.  All patient encounters with the office need to be better than expected.  By the way, if you do achieve this, you don't even have to ask the patient to refer, they'll do it naturally.  If you don't impress or inspire them with your service, there's nothing you can say to make them go tell everyone they know to come to your office.

Before we get too far, what about just having your staff scrutinizing the patient flow for referral opportunities?  Sure, that works so long as the patients weren't traumatized by emotionally unstable assistant or left waiting for the doctor for 45 minutes.  Usually, the incentive runs around $25 for a referral you can trace directly to the efforts of a single staff person.  The scripting and technique for this process is a topic for another blog.

So, what about marketing and the 7% of gross.  What do I need to know about marketing other than spending a lot of money on it?  I suggest we take up our next blog right here.  We'll lay out what works and what doesn't.  Who's really ready to market and who needs to fix a few things in the practice first.

A Starting Point For Growing Your Practice

In most cases doctors seek out a practice consultant because they want a better or larger practice but they don't know where to begin.  I'd like to share a few thoughts on simply finding a starting point for growing your practice.  Take a moment and see which of these conditions most closely describes your current situation.

1.  I don't have enough new patients.  I'm standing around with nothing to do while the overhead clock is running at warp speed.  I can tell that several of the staff really don't mind having some slow time during the day so they can catch up on other work, but I, on the other hand am experiencing high anxiety when things are slow.

I'm convinced that if I could get more new patients through the door I could reach my goals, one of which is a sense of the fulfillment that comes from being fully utilized.  Sure there are some busy times here and there but for the most part, my schedule isn't really challenged.  I've tried marketing, asking for referrals and I've even joined some local civic groups.  Is this ever going to change?

2.  I have plenty of patients but I'm pretty sure that the cases are not being fully developed.  In other words, there's lots of new patients but they're not accepting the treatment they really need.  I feel very busy but not terribly productive, does that make any sense?  If it's not disruptive composite cases, it's full-on new patient exams that end up as NTs (No Treatment).  Oh I'm busy all right.

I'm also hounded by the thought that we're not being very efficient.  I've often thought that if my monthly new patient count were to go up by 20% that I'd probably make even less money than I do now.  The practice is starting to feel like an unprofitable hamster wheel and it's wearing me out.  I always thought that if I could just get more new patients that all would be well, I was wrong.

3.  I'm reaching all my production goals but the profit just isn't there.  I hear and read about national averages for the typical dental practice but it just doesn't seem to apply to my office.  I've repeatedly gone over all the numbers with my accountant and I'm pretty sure we're not being embezzled or wasteful, the net just isn't there.  I've checked to see that I'm not overpaying my staff, my rent is within the 8% (of gross) guideline and my Patterson Rep is careful not to let my office become a supply warehouse.

My patients get high quality dentistry and first class service from a dedicated team of seasoned veterans.  My staff are well compensated, my patients are fussed over but it feels like all of this value is coming at my expense. I'm starting to wonder if I should have become an associate doctor or a manager at Wal-Mart.  At least I wouldn't have to worry about making payroll.  I hate to sound so selfish but there it is. I'm doing the work and delivering a great experience for both patients and staff but I'm not getting the paycheck I hear other dentists are getting.

All I'm asking you to do at this point in the process is to identify yourself.  I realize there really could be other perspectives on practice blockages but most of the ones I run into in the consulting trade fall under these three headings.  In the upcoming blogs we'll look into each of these frustrating conditions.  Stay tuned, we'll take them one at a time and in order.  You're comments are welcomed.