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Dr Roger P. Levin, founder and CEO of the practice management consulting firm Levin Group, joins the podcast to discuss the findings of the Third Annual Orthodontic Practice Survey. The joint project between Orthodontic Products and Levin Group looks at how practices fared in the last year—surveying everything from production, practice overhead, patient volume, referral sources, starts and orthodontic fees, appointment intervals, remote monitoring, and the challenges facing orthodontic practices.
Five key takeaways from this discussion:
1. Orthodontic production dropped slightly in 2023 but the industry remains relatively stable.
2. Rising overhead costs, especially related to staffing, need to be offset by increasing production through better systems and strategies.
3. Staffing challenges are a major issue for orthodontic practices and retaining existing staff is important.
4. Referral sources are diversifying and practices need varied marketing approaches targeting different referral channels.
5. Remote monitoring will likely play a larger role in orthodontics going forward, changing patient visit intervals and practice management.
Orthodontists will walk away from this conversation with insight into the issues and trends facing their industry and Levin’s advice on how to proactively organize the orthodontic practice for future economic growth. As he puts it, take advantage of today’s relative stability to set your practice up to thrive amidst any future instability.
Creators & Guests
What is Orthodontic Products Podcast?
Introducing the "Orthodontic Products Podcast", a journey into the dynamic realm of orthodontic innovations. Each episode dives into fresh research, transformative technologies, and the methodologies redefining the field. Expert interviews seamlessly blend with in-depth analyses, offering listeners a comprehensive look into the ever-evolving world of orthodontics. This isn't just a podcast—it's a portal to the future of orthodontic practices and breakthroughs.
Alison Werner: Hello and welcome
to the Orthodontic Products
podcast. I'm your host Alison
Werner. Today we have back with
us Dr. Roger Levin at the
practice management consulting
firm, Levin Group. He's here to
help break down the findings of
our third annual orthodontic
practice survey. Dr. Levin,
great to have you back.
Dr Roger Levin: Alison, it's
wonderful to be back. I love
doing the survey with you. I'm
glad it's our third year and I'm
looking forward to our
conversation today.
Alison Werner: Great well, as I
said, this is now the third year
and the survey asked
orthodontists to tell us how
their practices fared the
previous year. So we're gonna be
looking at 2023. Before we dive
into the details and get into
your advice to doctors and staff
who are facing some of the
challenges reported, what was
your overall assessment about
how orthodontic practices fared
as businesses in 2023?
Dr Roger Levin: Yeah, if I had
to pick one word, and I like to
do that, I would say stability.
Things were fairly stable. We
had a pandemic, we had a rapid
rise in overhead in 2022, the
biggest rise in overhead in any
single year, in the last 40
years. And in 23, it went up a
little bit more. But production
in practices in 22, and 23 was
fairly stable, we're going to
see that it's down a little bit.
It's not all it's not gloom and
doom. But I would say it was a
year of stability that this is
the first year since 2020, that
we are back to a more normal
landscape. normal scenario, we
don't have any huge problems,
even the economic problems are
limited, although the fact that
people are seeing some issues
with their everyday goods like
eggs and milk and things like
that where we're seeing a little
bit of a production drop. But I
want to be positive. Any
practice that looks like right
now can use the year 2023 as a
launching pad to do really well.
That's great.
Alison Werner: Okay, good. Okay,
so let's start by going through
some of the findings. And let's
start by talking about
production. How to 2023 stack up
against 2022?
Dr Roger Levin: So I love data
and statistics. And you can make
them sound like a lot of
different things. The fact is,
that production overall dropped
in orthodontics in 2023. Now, as
I said, it's not gloom and doom,
it dropped by about 4.7%. So
nobody has to panic, if I start
panicking, so I don't panic, but
I would panic. When I hear me to
practice this down 10% or more,
if they're down 10% in a year.
Any of you listening to this,
that's when you really need
action and help and turn around.
You don't want that to get
worse. I'm not real concerned
about the 4.7%. And I'm not not
concerned because it's a one
year data point. The question as
I wrote in the article that
you'll be publishing is, is this
the beginning of a trend, I've
talked a lot about orthodontics,
getting a little bit more
competitive. I mentioned in the
article, one of the biggest DSOs
in the country now offers
orthodontics through its general
dentists at $1,999. They have
their own branded aligner. So
whenever you see competition,
you've got to pay attention to
see how you're stacking up. The
one comment I make always is
your goal is to increase
production every year. It
doesn't have to be by a lot. But
if you can do that, if you can
increase production every year,
you are going to be somewhere
between good and great as a
practice.
Alison Werner: Okay. And you
talked a little bit before about
how we're kind of stabilizing in
terms of you know, those those,
you know, different those unique
years of 2021 2022 because of
the pandemic and everything. But
one of the things that is
happening or kind of looks like
it's happening in 2023 is that
that pent up demand due to the
pandemic and all the savings
that was built up is kind of
disappearing, and we're kind of
righting the ship basically,
Dr Roger Levin: Right. If I were
an economist looking at
orthodontics of the last few
years, it would be impossible to
get a handle on it because the
pandemic was so unusual. In 21,
the pent up demand many of our
client orthodontic practices had
record years even though they
were shut down for four to six
weeks. And they were exhausted
by the end of the year. In 2022,
overhead skyrocketed and there
was still huge pent up demand
coming in, people deciding to
have ortho. What what happened
to some degree was that people
weren't spending money. So they
were sitting at home saving.
They weren't spending it on
travel, luxury, entertainment or
restaurants. So there was all
this extra money. It wasn't the,
you know, 12 or $1,400 they got
from the government that let
them do it though. It was all
the savings. But by 23, we know
that savings is disappearing
right now. How do we know that
because credit card debt now is
back to an all time high, when
nobody, nobody puts interest on
their credit cards if they have
discretionary income to spend.
So we have definitely bumped up
against the excess savings that
people could use for ortho. And
now we're back to doing
orthodontics only for people
that really want it, not people
who in the past wouldn't have
gotten it, but they had extra
money so they decided to get it.
So I think that is a definite
contributory factor to the
slight drop in production in
2023.
Alison Werner: Okay, so keeping
that in mind and kind of some of
the other economic headwinds,
what strategies can practices
employ to continue to grow that
production?
Dr Roger Levin: Well, here's
what's interesting, you know,
I'm 39 years into this job. So
I'm, I'm almost at halfway in my
career at this point. And, and I
love I love looking at the
numbers over the years because
it tells us so much. The average
practice in 2023, produced
$1,535,000 and change. But we
know because I've built these
models over and over and over.
And we've worked with over 4700
orthodontist since 1985,
worldwide, mainly US but
worldwide, we know that any solo
orthodontist can produce $2
million a year in four days a
week, comfortably. We see we see
people, a small number, but we
see people that do that in three
days a week. You know, ortho has
what I call the volume factor.
Unlike the rest of dentistry,
you can put a lot of volume
through. And later probably
toward the end, if I'm
anticipating your questions, I'm
going to talk about how you
might be able to double or
triple the orthodontic practice
without working one more minute.
But for now, the main point is
there's a big gap a half a
million dollars or 25% between
where the average practice is
and where it can be. The other
way to say it is most
orthodontic practices could
easily increase production by
$500,000 if they have the right
strategies and referral
marketing in place, and that's
an enormous, enormous
opportunity.
Alison Werner: Okay. Okay. So
let's go back and talk about
practice overhead and what the
findings for this survey
reported or showed, and I know
it said you wrote that overhead
was on the rise. So yes, what
did what did practices report
for this year?
Dr Roger Levin: Yeah, well, I'll
start with the good news. The
good news is that the overhead
rise was pretty small in 2023.
It went up about eight to 9% in
22. It went up another one to 3%
in 23. Not not bad, it's slowing
down. You know, based on what I
know about production, and my
career has been dedicated to
identifying systems and
strategies to grow production.
Based on what I know about that,
which is fairly deep, we can
make up for a one to 3% overhead
increase in production in any
given year. But 59% of the
orthodontic practices survey did
report, they had higher overhead
and only a smaller number 13%
reported that overhead had
actually gone down. So it's not
a surprise, you know, the cost
of everything is up. And the
increased costs from 22 due to
supply chain due to staffing
heavily, I'll get to staffing in
a moment, those costs are not
going to come back down. So we
must increase production to
offset them. What I teach, which
is very well proven at this
point, is lowering overhead is
good, but you can probably only
lower it about three to 4%,
maybe five or six in rare cases.
But you know, if you've got
waste, you need to eliminate the
waste. The problem is overhead
reduction is finite, you can
only go so far. And once you've
done it, you're done. You can
only fire an assistant once
can't fire her twice or three
times. If you're trying to save
money, but production can
increase infinitely it can go up
two percent 5% 20%. Again, most
orthodontists underestimate
their real potential, which
unfortunately means they're not
as protected, that profit goes
down. The problem is if overhead
goes up, and it's not offset by
production, at least equally,
profit goes down. So we're
seeing a lot of practices that
even increased production and
profits still down three or 4% a
year. So what you want to do is
understand that lowering
production is a limited gain
rate. I'm sorry, lowering
overhead is a limited gain.
Raising production is an
unlimited gain. You can grow at
12% in a year or a lot of our
clients grow at 18% the first
year and the second year 18%
each. then that's going to
offset any two or 3% increase in
production with a 13 or 14 or
15% increase in profit. So,
overhead's going up, it's going
to stay up. Why? Staffing is a
crisis. It's a different podcast
for us to do someday, Allison.
Yes, I get every dentist I talk
to every new client that comes
in is struggling with staffing.
And I could I could list the top
10 negative factors of the
staffing situation today. Bottom
line, we've got a shortage. It's
not going away anytime soon. It,
I think it's with us for at
least 10 years, and I can't see
beyond that. So we need better
systems, smoother running
practices, more technology to
offset labor. But in the
meantime, staffing is up about
10%. And that means production
has to go up at least 10% to
offset the staffing increase.
It's not going to come back
down. So if anybody's waiting
for it to reverse, it's going to
go up more, it's not going to
come down. We have some real
challenges in staffing, which
are number one, there are people
who are afraid to work in
medical and dental because of
they're still worried about
COVID. I know most people are
saying, oh, it's over. But
there's still people who are
worried. Number two, a lot of
people now want to work from
home at least three days a week,
those people are not taking jobs
in orthodontic offices. So
they're off the table. And
number three, we had about six
to 7% to 8% of our orthodontic
staff retire at all ages, they
just decided that they're done.
And I guess unless they become
financially challenged, they're
not coming back. So we have a
smaller labor pool. We're hiring
less experienced people that
need training, and the costs are
way up for all of that. And if
you look at minimum wage, now
there are articles every day now
about minimum wage in
California. It'll be the rest of
the country, $20 an hour for
fast food. That's a that's a 25
to 50% increase in labor. We're
only a 10% in orthodontics right
now.
Alison Werner: Okay. Okay. So
that it's time to start figuring
out other other strategies. Oh,
yeah, absolutely.
Dr Roger Levin: Again, you want
to we can talk about this later,
if you want. But you want to
keep the staff you have that's
the best way to avoid all the
other pain?
Alison Werner: Yeah, well, I
think that the message here is
we're going to do a separate
episode on just staffing. So
look forward to that. Stay
tuned.
Dr Roger Levin: I've been doing
a lot of work in that area,
because we have to.
Alison Werner: Yeah, yeah, I
know. Yeah. Well, let's talk
about patient volume and what
the survey found, because that
does tie in to dealing with, you
know, countering overhead, you
do need to get that production
up. So you need that patient
volume to be up. So was it up?
Or was it down?
Dr Roger Levin: Well, it 72%
said it was the same or up?
Which is interesting, because if
production's down, you know,
little under 5%, how is volume
the same? And the answer is
several things. Number one, the
volume of referrals does not
always reflect the volume of
starts. So referrals may have
been steady, and we're going to
talk about that I know. But the
starts may be down we have more
shopping, we have more options,
we can go to a DSO staffed by
general dentists, we can go to
general dentists who are doing
aligners. And that's really
interesting when we get to where
referrals are coming from. This
was a really interesting
finding. But six, it's
interesting that 72% said that
their volume was about the same.
So I found that interesting. But
in reality, their volume wasn't
rising. And it may be that if
you don't have more patients, a
higher percentage converting to
starts, then you need higher
volume to make up that
difference. So the fact that we
don't have higher volume is the
thing to really pay attention to
don't get comfortable saying,
Oh, I've got the same number of
referrals or consults. And by
the way, it's not in this
survey. In another look, we
found that up to 16% of parents
or patients that call an
orthodontic office, never make
an appointment for a consult.
Nobody tracks that. So we didn't
ask it in the survey because
nobody would know. But we did
take a hard look at a large
number of client offices and new
clients so that it was random.
And we found that when we start
with them, many as they start
tracking, have a number of calls
coming in that do not schedule
for consults. And they're asking
questions like well, how much is
ortho or how long will it take
or do you do this type of
procedure? The front desk staff
are not well trained to handle
those questions. We need
scripting for that.
Alison Werner: Okay, so that
they the inquiry from the from
the prospective patient snd our
consumer is changing.
Dr Roger Levin: Right and the
front desk staff and they're
very nice people, I have great
respect for them. But they are
only good right now at the
standard basic new patient
Alison Werner: Right? It sounds
like it, especially as you know,
calling and wanting to make an
appointment. They're not good at
building, it's not something
they can learn it, they can
easily learn it. Yeah, but
they're not good at building
value in the mind of a patient
that has questions. So every
practice should at least write
scripts for the top six or seven
questions that you get from a
new patient call or this is this
is now a good idea. In the
future, it's going to become critical.
consumers now can, to a certain
extent can better comparison
shop, even just online to get
you know, what are the average
prices in my region? Or, you
know, they do have those ads
from those DSOs? Like Aspen.
Yeah, it's freely advertising
very publicly advertising what
they charge. So
Dr Roger Levin: we've gone from
years ago saying things like,
well, we'll tell you that when
you come in, and that work back
then to focusing on value
building, the new patient call
is the first step of what Levin
Group calls the new patient
experience. And if you don't get
that, right, you have missed the
boat in a big way. And your
start rate, they may not come
in, they may not show up. And
they may not accept treatment
all higher, if you don't have a
great new patient experience and
value building process in that
first phone call. So the front
desk person has to think of
themselves as the first
treatment coordinator they meet.
And then they come in and they
meet the second treatment
coordinator. That's how I view
it today.
Alison Werner: I think, yeah,
that actually that actually
makes a lot of sense. So. Okay,
well, so let's break down the
sources of new patients. What
were, what did respondants say?
Dr Roger Levin: Yeah. So I want
to warn everybody, there's a lot
Yeah. So what's your overall
takeaway from this information
of bias out there about
referrals from general dentists,
about referral sources?
we, you know, and I want to warn
you, this is data. This is not
my opinion. But this year, it
was a change as the number one
source of referrals. The number
one source was from referring
doctors. And it's this is really
interesting, because what we
show in our surveys is that
approximately 3.6 billion with a
B, $3.6 billion of revenue is
referred each year from general
practices to orthodontists. Now,
may have been more five years
ago, we're only in our third
year Alison of doing this with
you. So we don't really know.
But the number one source of you
know, 38% of patients were
coming from referring doctors.
So I, I want to be careful
because that's the kind of we do
we have a whole program and
referral doctor marketing, and I
don't want to sound like I'm
leaning towards something,
because that's what we do. This
is complete data completely
objective. But I encourage
people build your referral
marketing also, for referring
doctors. Don't say they're doing
all the ortho or they don't
refer. We find a lot of new
clients who tell us that they're
not getting referrals from
general dentists because the GPs
are doing all the ortho. We find
two things. One, they're not
getting referrals, but the GPs
are not doing all the ortho they
might do some, they're referring
it to other orthodontists. And a
year later, were getting lots of
referrals from referring
doctors, they had just never
focused on it. And since it
didn't just automatically
happen, or it didn't happen
after a few strategies, they
decided, well, this isn't going
to work, and they gave up on it.
Well, if you're not doing
anything, there's a very good
chance you won't get referrals
from referring doctors. I'll
read you the list, which I have
in front of me after after
referring doctors, number two
was referrals from existing
patients. So a lot of dentists
think they're just orthodontists
rather think they're just so
well known in the community. And
they may be, but it's really
referrals from the parents and
patients that are a huge
segment. So you don't want to
just have, you know, little
little contests for the kids.
You want to have, you know,
eight, nine, 10 different
strategies. We have offices
right now giving out the new
Apple virtual reality glasses.
Now they're $3,500. So you don't
buy 10 of them. What you do if
you buy one, and you make it a
six month contest, where people
can enter the win, and then it's
$3,500 over six months. So for
some practices, that's a great
idea. Third, was referrals from
existing adult patients. Now
that's going up regularly. You
know, in the past, adults were
not the big referral sources,
because we didn't have aligners.
They didn't want to do bracket
and wire. And honestly a lot of
orthodontists don't like
treating adults because you
know, they've got an opinion
they are not as easy as the
kids. They don't come in with
their air pods and never have to
talk to you to talk to. So the
adult, I've said for years the
adult market was the greatest
unexplored frontier and I'm
predicting that this adult
referrals are going to grow as a
percentage of practice referrals
every single year from here on
for a long time. Third was
social media. But it's not
growing. It's interesting.
Social media is so hot, with
orthodontists. And I like it,
and you should have it, don't
misunderstand me. But number
one, it's hit or miss. I, we get
new clients who are doing well
with social media and we get new
clients who are not doing well
with social media from the same
social media companies that they
work with. So nobody has, you
know, every social media company
I talked to, because we get
called a lot would you recommend
us to your clients, and they
always kind of come at it from
because we're, we have this
secret way of doing things that
gets results, everybody thinks
they have the secret sauce. And
the truth is, there's no secret
sauce, or we would all know it
because everybody be reading
about it or publishing it
online, or Google would tell us
or whatever. But social media is
important. But it's not growing
as a referral source. It's flat,
which is fine. And it's a little
bit up from 22. It went from 12%
and 21, to 9% and 22, back to
12%. So if you only look at last
year, and the 22 and 23, you
might say it's up 3%. That's a
true statement. But it's only
back to where it was in 21. And
again, I spent a lot of time
looking at this data to try to
understand it. And finally, the
thing that dropped off,
interestingly, was community
activity. Yeah, right. Now, I
have different theories. And I
don't know which ones right
because I don't have any data
yet. Okay. orthodontists
spending less on community
activities, because of the
pandemic or ortho which is over
mostly, or orthodontists
spending less because things are
more expensive. Or, or is it
just less effective, and people
are relying on other sources for
their referrals going forward? I
don't know yet. But I'm gonna be
really interested. I made a note
next year, the first thing to
look at is referrals from
community because if it's flat
or down, then that's a new trend
that we're looking at. It could
have just been an off year. I
don't know.
effort, we meet people that only
focus on the patients, we meet
people that only focus on social
media. And that's great until it
runs out. And usually, they
don't realize it's running out
till about three years late.
orthodontists have what I call a
three year mentality, we don't
wake up and pop up with a sign
that says, Oh, I have a problem
till about three years in, and
then and that, then it takes
longer to reverse. So number
one, I would diversify between
referring doctors, patients and
parents and include a subset of
adult patients, the community
and social media. But I would
not do it evenly 25% 25, 25, 25.
Based on this data, I would put
more investment into referring
doctors, I would put the next
most investment into patients,
the third investment into social
media, and then the fourth
investment into community, I
would stay with the community,
but I would back that down quite
a bit based on what I see here.
Now, having said that, you have
to monitor your referrals, you
got to understand referral
marketing, you need a minimum
quantity. The big secret here is
not just to have quality, you
know, a good social media
campaign of high quality doesn't
do it. You got to have quantity.
How many times do you have to
touch referring doctors? How
many times do you have to touch
parents, patients and adult
patients? How many impressions
do you need with social media?
You know, back in the old days,
when we only had print
advertising, the you may
remember this, they said it took
17 times see an ad for the ad to
be effective. Well, social
media, it could be 78. For all
we know, you'll we just don't
know. So based on this, I would
definitely stay diversify, but I
reallocate where I'm
emphasizing. And if I were a new
orthodontist, I would go out of
my way to build my general
dental referrals, even if
they're doing ortho, most of
them are definitely not doing
all the ortho by any means.
Alison Werner: Yeah, right.
Okay. Okay. So now let's switch
to challenges and we've touched
on a few of these already, but
we asked orthodontists to
identify their top challenges
for 2023.
Dr Roger Levin: Here you go.
Alison Werner: Yeah,
Dr Roger Levin: This comment
first. I am a huge believer in
the economic law of supply and
demand and in almost every
survey I'm ever involved in and
we're involved in others and the
rest of it industry. We do
surveys for William Blair, the
largest Wall Street analysis
firm to analyze public
companies. So they want all the
data, they engage us for
proprietary surveys. I always
start before I interpret by
asking, does the law of supply
and demand apply here? So what
does that mean? For many years
and back when I was in practice,
as a general dentist, everybody
did well. And we all thought we
were brilliant and good at it
and great practice builders. But
to a large degree, we were
fortunate that the supply of
dentists and orthodontists was
low, relative to the demand for
services. So it's not a matter
of being lucky. But the fact is,
we always we all look brilliant,
when the supply is low, and the
demand is high. Well, that's
shifting now. And it's shift,
it's past the neutral point,
it's starting to shift where,
and I've talked about this with
you before 25% of practices are
going to have better careers
than ever in history. And the
next 25 are going to have good
careers. The next 25 are going
to have much tougher careers and
the bottom 25 may not even make
it they may end up selling and
working for someone else. We are
seeing that fragmentation. So we
have challenges today. And the
biggest challenge is not enough
patient starts. Well, sure
because if I have enough patient
starts, then nothing else
matters. I've got I've said
forever, the only two things
that really mattered and
building a world class ortho
practice, are the number of
referrals and the number of
starts, everything else is just
operations. Yeah, every
orthodontist can do most of the
cases really well. You have to
have patients. So yes, patient
starts was right. And these are
not my rankings. These are
ranked, we have eight, I'm gonna
read all eight. We have eight
challenges that were ranked by
the orthodontist in our study,
and this is what they reported.
Yeah, so challenge number one,
not enough patient starts. Well,
what that really means is not
enough new patients. And it
wasn't reflected heavily in the
data, but they may be feeling
something. And I've always said
when orthodontists feel
something's wrong, they're
usually right. People will call
me and say, I just feel like
we're slowing down and their
practice is still stable. But
when you feel it, you're just
ahead of the curve. In most
cases, you're right. So if
you're feeling something, you're
probably right. So number one,
not enough new patients starts
that was reported by 71% of the
respondents. Number two, rising
overhead, well, that's a vestige
of 2022. If we stay stable from
here on, then a couple years,
the fact that it's higher than
in 2022, everybody will forget
that and just say, Yeah, we're
Alison Werner: Kind of flatline.
Dr Roger Levin: Flatline,
that's, that's a great word. And
Yeah, that's a good point. And
so maybe that's something we
you don't want to do that. And
Alison you summed up the whole
thing beautifully, better than I
could. Number three, ability to
and it's interesting ability to
retain and hire clinical staff.
Now, why is that so interesting?
Because in the general practice
survey we do separately from
this, it's published in a
general practice publication,
this was number one, staffing
was number 1 in 2020, number one
in 2021. Number two in 2022.
Overhead took the number one
spot, but back in 23, back to
have to look at in the future
surveys is that,
staffing being number one. So I
was kind of surprised to see
this as third, but 48% said they
staffing is a huge challenge.
But we also know that 64% of
orthodontic practices are
currently looking for one or
more team members to add either
as replacement or additive.
Number four competitive threat
for GPS, 38% said that, that is
more subjective. I my theory I
could be wrong. My theory is
they're more focused on it
because they're annoyed about
it. They don't like GPS doing
ortho. It means they're not
referring to the orthodontist.
They don't feel the GPS
necessarily have the skill set,
which is kind of true in that a
lot of GPS do aligners because
the AI is in the trays
artificial intelligence. But not
because the GPS like me have any
additional ortho training. So I
think there's a bias there. But
either way, as I've said to many
orthodontists get over it and
deal with it because it isn't
going away. Number six,
declining insurance
reimbursements, always a
challenge. Seven, competitive
threat from DSOs. That one's
going to move up that one's
going to get bigger, because
DSOs like ortho and they're just
Well, there's a company out
there, I know, we're gonna get
starting to add more and more of
it. And some of the big GP DSOs
are starting to add specialists
as well. And number eight,
competitive threat from direct
to consumer. Well interesting,
that that was number 8 all the
way down at a lowly 6% because
it's basically gone. Will it
come back? Who knows? Yes, not
here now, I would worry more
about AI and aligners allowing
GPS to be, you know, just
distributors for aligners to
their patients. That's a reality
that I talked about in my lectures.
to this, so I want to do it now.
But they've got like, 126 data
points now. Not not for
aligners, but under, but for
monitoring. And I'm studying
monitoring really deeply because
it's going to be a huge factor.
And a lot of orthodontists are
still in the denial stage. And
I'm not an orthodontist. I don't
tell people how to practice. I
look at market forces. And in my
career, I've been very fortunate
and looking at market forces and
saying, Okay, this is something
that's going to explode with
growth once it hits the
inflection point. But again, my
point was not that it's AI
driven. AI is going to play a
bigger and bigger role in the
whole world plus orthodontics.
Alison Werner: Yeah, absolutely.
Absolutely. Well, one of the
things you break out in the
article is you do go a little
more in depth on dealing with
the staffing challenges, which,
you know, in this year survey
did start it came in at number
three. So you identified three,
sorry, four opportunities, or
no, actually, I've got four for
the top answers for Yep. Okay.
Dr Roger Levin: So, here's
what's really important.
Staffing is not a shortage, it
is a crisis. And even if your
production is not dropping
because of it, which does
happen, the rest of your staff
is exhausted. So if we had six
or 12 hours, I can talk about
staffing from every dimension
plus burnout. I've read four
textbooks now on burnout, just
to understand the difference
between fatigue, frustration and
burnout. And again, that's not
for today. My main message is
you want to focus on staff
longevity, you want to measure
that every year. And I can give
you many, many, many things to
do. But let's go through the
four. What four things did
orthodontists say. This isn't,
today's podcast is not about
what Roger thinks. If, if you
think Alison, it's very
important if I think it today
it's not. It's it's about what
did our respondents say. And
they came up with four key
things that they're doing to try
to retain their staff. Number
one, increasing base
compensation. Okay, that's a no
brainer, because you're not
people aren't gonna take jobs if
you don't pay them enough. And
everybody knows, with full
transparency, what everybody's
making. And if any of you have
an illusion, that your staff is
not sharing their compensation
every day at lunch, then you are
living in the Dark Ages. They
they know exactly what
everyone's making. There's,
there are new laws. Now in many
states where you have to publish
the compensation in your ad by
law, and it's going to go
national, it's going to be
everywhere. Yeah. Remember, it
is a labor market, everything
happening is in favor of labor.
And I don't take sides I have to
deal with what's happening. A
lot is gonna be a lot of
regulations going toward labor.
For, here's an example, we have
a client in California, that had
to pay a fortune to a 20 year
employee who quit because they
never gave her 10 minute breaks
on the regulation cycle and she
came back and sued and a lot of
money. It was not small money
there. There are laws on when
you get breaks how long lunch
has to be in different states,
every state is different. But
pay attention. Yes, the number
one increasing space
compensation. Number two,
providing more bonuses and
bonus, the word bonus, you have
to be careful, has a lot of
different meanings. I've written
a book on bonuses. And it's it's
one type of bonus. But there are
many there bonuses on
compensation, their bonuses on
number of conversions, there are
bonuses on completing cases on
time, and overdue debonds, there
are bonuses on collections. You
tailor the bonus to what you
need to focus on in your
practice. Right now, if you put
if you put a gun to my head and
say, Well, what is the best
bonus? Now that I've said, well,
there isn't just one, it would
be a production based bonus for
the team where everybody shares
equally over a certain amount.
So a bonus is not a giveaway,
and the Christmas bonus is not a
bonus. Nobody cares. Nobody
thanks you. It's the 27th
paycheck. If you're if you give
Christmas bonuses, it's just
expected. Number three adding
technology for productivity
enhancement. This is going to be
big and technology. It's early.
It's very early despite all the
workflow technology, I am now
studying workflow technology,
and how it can increase
production and efficiency and
even replace certain labor and
certain functions. And the
reality is that technology is
going to be essential. Simplest
example, you walk into a
McDonald's, there are no
cashiers, you order at a kiosk,
and then you pick up your order.
Why? Why is that happening?
Well, originally, it started to
save money in the testing phase.
But now because they can't get
people to work there, and higher
minimum wage is getting very
painful. And finally, number
four, offering more and better
employee benefits, there are
people to health care is a
fortune. There are people that
want health care, they want to a
lot of orthodontists do not give
dental benefits, which is kind
of ironic.
Alison Werner: Yeah, I've heard
that. I've heard that.
Dr Roger Levin: You know,
general dentists can give it
because they can do most of that
stuff. You know, it's there's a
cavity or whatever. But a lot of
orthodontists don't get dental
benefits. Vacation time is going
to become more important. You
can't give this benefit, but
working from home is a benefit
that a lot of employers are
giving in the business world or
working from home part time, or
paying part of a gas allowance
or things like that. So there
are a lot of different benefits
and you need to tune into what
matters to your orthodontic
team, because that's how you
keep them. What matters to your
team is very important. So those
are four items that are being
reported by our respondents. I
agree with all of them. If as a
as the CEO of a consulting firm,
these are all great ideas.
Alison Werner: Okay, all right.
It's good to know that they're
on track there. Okay, so let's
talk about starts and
orthodontic fees. So the average
number of total starts per
orthodontists for, let's say
bracket and wires we reported
204 is the average number of
starts per orthodontist; average
fee for complete treatment for
brackets and wires was 6,287.
And then clear aligners, we had
83 average annual starts per
orthodontist and an average fee
for complete treatment $6,467.
Dr Roger Levin: Well, first
thing is what's happening with
aligners. Again, anything I do
an ortho, what's the aligner
effect, I call it I look at that
intensely. It was fairly flat
and growth last year in
orthodontic practices. There is
going to be an explosion; I'm
still predicting five years from
now, it might be as high as 70%.
Everything's getting better the
AI is getting better. The
biggest companies done 22
million plus cases if I'm in the
ballpark anyway. We know so much
more. We can do it for teens, we
can do it for younger kids, now.
It's, again, market forces, it
started with adults. Then
aligners went to teens, and it
went to younger and eventually
we'll be doing them in utero. So
probably the next few years, but
the point. So it's very
interesting aligners have not
grown as much in ortho.
Obviously, they're 95% plus in
general dentistry, because
that's all they can do. But
having said that, I think
aligners in the next few years
I'll be shocked if these numbers
don't explode, as because
they're more and more parents
and patients that are just not
going to tolerate anything else.
They want aligners, and there'll
be practices that are more than
happy to do that for them, if
your practice doesn't. What's
really interesting are the fees.
You know, we first started with
aligners, partly because of that
$1,800 lab fee that was out
there, everybody put a much
higher aligner fee than a
bracket wire fee. They also
didn't have the competition was
between orthodontic practices,
not all these other service
delivery models. Well, now that
that's changed, I'm not
surprised that the bracket and
wire fee and the aligner fee are
pretty close to within a couple
$100 of each other. And that's
the big takeaway: Watch your
fees because you are competing.
You could you don't have to have
the highest fees, you have to
have higher volume, which means
more systems, better staff
training, more scripting, better
run practice, more efficiency.
You can be very profitable that
way, but if you raise your fees
too high, you're gonna lose a
lot of cases and the tolerance,
where I still predict we're
gonna see orthodontic practices
with two tiered fees where the
sixty 62 and 6,400 is the high
end. Listen, I know there
$10,000 cases out there, and
maybe half of that might be the
lower end and I think we're
gonna see both. Again, market
forces otherwise, what practices
will start doing it when they
don't have enough starts. We're
not there yet. I hope we never
get there. But unfortunately, I
think we're going to get there.
Alison Werner: Yeah. Okay, so
now let's look at the changes in
patient visit intervals. So the
time in between checks. So for
let's see, treatment for bracket
and wire for in person visits
we've got seven weeks is the
average time between visits; for
for remote monitoring visits for
bracket and wire, we've got
eight weeks, and then clear
aligners, we've got 10.1 weeks
for in person visits and 14.7
for remote monitoring visits. So
what's the takeaway here?
Dr Roger Levin: Well, there's
several takeaways. First of all,
it's up a little bit. And you
know, bracket and wire, seven
weeks, remote monitoring, eight
weeks, I want to tell everyone,
before I make any more comments,
I'm not speaking clinically. We
have never told an orthodontist
how to practice. That's not what
we do. But we can tell them
what's happening out there. And
it's very interesting with
aligners, 10.1 weeks, and remote
monitoring, 14.7. So let me tie
some thoughts together, remote
monitoring is going to grow
very, very quickly. It will
become part of every ortho
practice in the country, or 90%
of them, and in within five
years. It's just there. Now,
anybody listening that doesn't
like remote monitoring—and
that's a lot of you, I
understand that today. But
remember, we didn't like
aligners when they first came
out either way, if we don't like
a lot of things when they first
happened. Yeah, I'm gonna
predict that this is going to be
huge. The market forces are
there. I'm studying it, it's
getting, it's getting better
monthly. A lot of practices have
no idea how to manage it. They
don't know how to put in place a
remote monitoring staff member;
they don't know how to make it
work. But it's going to come.
And we're, it's so important.
We're starting to incorporate
how to manage it into our
consulting because we're there;
but you know, again, I don't I
don't want to be behind for
people. And if somebody doesn't
need it fine. But we're putting
in our program how to deal with
it, because we're there. So, but
here's, here's what I'm going to
say and this is my opinion. Now.
It's a mistake. These intervals
are way too short. I think we're
going to find I have clients
very fine orthodontists very
dedicated, very smart, where
it's with aligners, it's 18
weeks between intervals, but
with remote monitoring, it's 24
to 28 weeks, we even have
somebody at 32 weeks, and as far
as I know they're highly
dedicated. They're not we know
they're not getting negative
feedback because we survey
patients in our program. And
again, ultimately, they want a
beautiful smile. I always
explain to orthodontists and
TCS, forget everything else,
gear everything toward one
thing, the beautiful smile. But
these intervals are going to
grow. And I encourage
orthodontists take a hard look
at making them longer. You don't
you know, I'm not telling you
had a practice, if you don't
believe in it, that's fine. But
otherwise, you're only at this
cycle because of basic habits
and your comfort zone. But with
remote monitoring, everything's
going to change. We have a
company in Europe, also for
dental, dental and ortho
consulting, and in Europe, there
are orthodontists that see the
patient for the start and
everything else is remote
monitoring. Now, I'm not
promoting that. That's not my
role. I'm not a clinician, but
Europe's way ahead of us in
terms of the intervals, and
they're comfortable with it. Now
somebody might say, well,
they're not as high quality as
we are. I'm gonna challenge that
we won't know for a little
while, but I think they're just
more open to this particular
methodology of interval setting.
Alison Werner: Okay, well, you
we also ask the question of how
what type of appointments
doctors are conducting remotely.
So the number one type of
appointment was the orthodontic
check. Then we did new patient
consults, retainer checks,
emergencies and then new patient
exam. What kind of was your
takeaway from that?
Dr Roger Levin: Oh, it makes
perfect sense. I think
orthodontists often view the
check as of minor importance.
Now if you've got to change a
wire or something, that's fine.
But the orthodontic check is
just that it's a check. And
it's, that's an orthodontist do
most of the afternoon. Check,
check check. Frankly, a lot of
staff members can do it pretty
well. So 72% are using some type
of monitoring or teledentistry
for checks and ortho is the only
part of dentistry really using
teledentistry, it's under 3% in
general practice. It's not going
anywhere. You know, during the
pandemic, everybody was
predicting where it was going to
go and wanted to invest in the
companies. And these aren't
microchips. Now teledentistry is
going to have a very minor role
in general practice, oral
surgery, endo, perio, pedo. But
for ortho, it's fantastic. You
can save so much time. I love it
for checks. I would do as many
checks as you can remotely. In
terms of the new patient consult
Alison Werner: What about that?
Dr Roger Levin: Well, here's the
thing, be careful. The
technology is fine. But we don't
know what happens when you don't
have a live meeting and room
consult and relationship. I am
very concerned about practices
is trying to do their new
patient exams and consults
remotely, I think that I don't
think that's going to be good.
You need to get that parent and
patient in to select you. Third
retainer checks. I have said for
30 years again, my opinion, do
twp, and they and by the way,
they won't show up for the
second one anyway. So 50% on
retainer checks don't come in on
average. Think about that. 50%
though. So they're just a waste
of time, they eat up chair time
you're never getting back.
You're losing it permanently. So
I love it for retainer checks. I
think I think remote monitoring
for retainers will be over 70%
within five years easily.
Emergencies, fantastic. Because
what you're really determining
is, do they need to come in?
That's all and how quick. Yeah,
is it emergency? Yeah, stop
blowing up your schedule and do
a remote exam. And finally, the
new patient exam. Again, be
careful. Right now, I would
advise clients get new patients
into your office so you can
control the incredible new
patient experience. And they
start with you. So but ortho
checks that's only going to rise
and rise rise. That's the easy
one. And that's almost double
the next closest remote
monitoring.
Alison Werner: Okay, so another
issue that came out of the
survey findings was we found
that almost one quarter, 22% of
orthodontic practices do not
have a full time treatment
coordinator. What's the takeaway
from...
Dr Roger Levin: It's the first
time we've asked that, and I was
shocked. I was absolutely
shocked the way we asked it. If
you don't have a TC, get one.
Number one, they will save the
orthodontist so much time you
know, even though ortho goes
chair to chair to chair, you
still have to look at it from a
doctor production standpoint.
Every time a doctor is at a
chair that's production. Every
time a doctor is at a consult
that's not production. So excuse
me kind of sneeze there. So we
want orthodontists in the main
clinical area with parents,
patients and adult patients as
much as possible. We the
throughput, the volume we can
put through is much bigger in
most ortho practices. Remember,
let's cycle back to the
beginning. They're mostly
running $500,000 a year,
production below potential. So
you want to get a TC. Number
two, the TC is going to spend
more time. These are hour
consults, you build
relationships, you learn about
the parent, the patient, you
learn why they're there, you
build commonality. And what we
teach, and we teach it minute by
minute, step by step, build a
relationship. It's not just a
sales job, it is building a
relationship to build trust to
get a start. That's what you
really want. You want mom going
home and 80% of the time it's
mom saying to her husband, we
this is where we need to go,
this is the right place, we're
not going to another place for
$400 less, because the husband
wasn't there. It's typically the
husband, when mom comes home and
says oh, we went to the
orthodontist today this is get
another opinion. So you know,
because even in our equal world,
husbands do a lot more of the
daily checking account, they're
watching some of the money and
and men are often more likely to
bid it out. Especially if they
didn't hear the presentation. So
you need a TC that's trained
exactly what to do. And the TC's
today are not the TCs of even
five years ago. They need to
understand there's competition
out there you need to be
building your scripting to
incorporate why come here before
anybody asks you or doesn't
bother to ask you. So the TC
today has to build value, not
just explain orthodontics, you
can't take a former assistant
and stick them in that role with
no training and expect them to
do well. This is a professional
sales position to build
relationships engender trust,
and create starts and then
measure them and measure them
and measure them.
Alison Werner: Okay, so what's
your overall message to our
listeners and our readers?
Dr Roger Levin: Well, I started
by saying the word from this
survey is stability. And that's
a good thing stable is good, but
stable doesn't stay stable. And
when I look at the trends
between an economy where some
basic goods and staples are
costing more money, and that's
what people look at, in an in a
competitive landscape where we
have DSOs and general dentists
doing more with aligners. We
have ortho only DSOs but we've
got the big boys and orals as I
call them starting to bring in
more ortho because it's
lucrative. We've got staffing
challenges, and which even we
put aside the frustration, and
headaches, we've got higher
overhead that needs to be offset
by higher production. So my
message is, if there was ever a
time to organize your practice,
streamline it was systems, get
everything in place as if you
were declining, even if you're
not, this is that time, because
right now we're stable. So
you've got time to get it right.
But if we happen to go into some
decline, as I think a lot of
practices will in the next few
years, not, I'm not gloom and
doom, not tomorrow. But the best
time to build is before you have
a problem. And it's also easier
and faster. But I'll end where I
started. Any practice can do
well, if it applies the right
methodologies and systems and
practice management. But you
can't just rely on that economic
law of supply and demand
anymore. It's not as much in our
favor as it used to be.
Alison Werner: Yeah, absolutely.
Well, Dr. Levin, thank you so
much for taking the time to
break this all down for our
readers and
Dr Roger Levin: our listeners.
Thank you, Alison, is always a
pleasure to be with you.
Alison Werner: Great well, and
to those of you who want to
learn more about the survey, it
will be in our upcoming
April/May issue, which will if
you don't get it in the mail,
then you can also find it at the
AAO at our booth. And you can
also find the article online and
we'll have a link to the full
article with this podcast. If
you go visit our website. So
thank you for joining us. And
thank you again, Dr. Levin. As
always, thank you for joining
us. Be sure to subscribe to the
Orthodontic Products podcast to
keep up with the latest
episodes. And be sure to check
out orthodontic products online
dot com to keep up with the
latest industry news. Until next
time, take care.