Current
Trends in Efficient (?) Orthodontics
By Dr. Dean
C. Bellavia
For the last 15 years the trend towards running a more efficient practice has had positive and negative repercussions. While some practices try to keep a balance between services and efficiency, others overstress efficiency detrimentally affecting their services. The major areas for increasing efficiency seem to be: the appliances used (brackets, archwires, etc.), the initial and retention appointments, and the weekly interval between appointments. Self-ligating brackets and heat-activated archwires have proven to be efficient in treatment and chair-time, but this may not be the case with reduced services at the start and end of treatment and extending the intervals between appointments.
The Two-Step vs. the One-Step
Consultation
It is inefficient to spend
30 to 45-minutes on a treatment consult unless it improves cooperation and
reduces extra treatment appointments; thus, losing sight of the purpose
of initial appointments can reduce overall efficiency:
Ÿ Purpose of the EXAM appointment is:
Ÿ
To establish patient
rapport, address concerns, allay fears and make them feel important and cared
for
Ÿ
To evaluate/indicate the
patient’s orthodontic problems, treatment and fees
Ÿ
To provide realistic fee
payment options
Ÿ
To sell the patient on
diagnostic records and getting started
·
Purpose of the Records
appointment is to obtain sufficient records for adequate diagnosis
Ÿ Purpose of the Tx Consult appointment is:
Ÿ
To have the patient
understand the orthodontic problems and treatment goals
Ÿ
To finalize a realistic
payment plan, informed consent and HIPAA issues
Ÿ
To schedule all starting
appointments (extractions, separation, braces, etc.)
Comparing Total
Numbers of Starting Appointments
Ÿ
Ideally, the Two-Step consultation requires three
appointments: exam/records, consult/sep, and braces; although, records/sep may
be a separate appointment
Ÿ
Ideally, the One-Step consultation requires two
appointments: exam/consult/records/sep and the appliance insertion, although
records/sep may be a separate appointment.
Comparing Total
Appointment Time
Ÿ
Typically, in the Two-Step approach, the
separate Exam and Tx Consults take from 30 to 60 minutes each (averaging 45
minutes each), plus from 30 to 75 minutes (averaging 45 minutes) for records
for a total of 135 minutes.
Ÿ
Typically, the One-Step Exam/Consult takes
from 75 to 105 minutes (averaging 90 minutes), plus 45 minutes for records for
a total of 135 minutes.
Comparing Financial
Control
Ÿ
The Two-Step approach presents the fee and
possible financial arrangements at the Exam, insurance processing between exam
and Tx Consult, and finalizes the finances at the Tx Consult.
Ÿ
The One-Step approach creates problems with
effectively processing financial agreements, although an extra “financial
consultation” visit helps. Cases may be
misdiagnosed at the exam requiring treatment and fee adjustments after the
doctor’s case work-up, although a pre-exam Pano/Ceph reviewed by the doctor at
the exam reduces misdiagnoses.
Comparing Cooperation
Control
Ÿ
The Two-Step approach encourages patients to
be a part of the treatment team by making them aware of and committed to
cooperating.
Ÿ
The very long One-Step
exam/consult/records/sep visit could make the patient aware of the cooperation
required if the patient wasn’t too “burnt out” to understand.
Bottom Line
Ÿ
There is one less appointment using the One-Step
approach.
Ÿ
There is less financial control with the One-Step
approach, even with a separate financial consultation.
Ÿ
There is better cooperation control using the Two-Step
approach.
Ÿ
The One-Step approach should be used in
practices exhibiting poor people skills to get them started before they have
time to change their minds.
The Short vs. Long
Retention Period
Ÿ
Classical retention consisted of 6 to 10 retention
check appointments that lasted 2 to 3 years (or indefinitely). Current trends range from 2 to 4
appointments over 6 to 24 months, averaging 18 months. It is probably best to have at least 12
months of retention in 3 to 4 appointments as long as relapse is under control,
which should be determined by the patient’s overall cooperation. There are many philosophies about retainers,
but there seems to be a trend towards fixed retainers for shorter retention periods.
Ÿ
All practices need an “End of Retention” letter;
signed by the patient/parent, indicating your retention philosophies and the
cost of extra retention visit from then on.
The 9-12 week vs. the 6-8 week Treatment Appointment Interval
Programmed brackets and specialty archwires allow for shorter appointments and increased appointment intervals. Unfortunately, there is a fallacy in thinking that an increase from 6 to 8 weeks is 25% fewer daily appointments, an increase from 6 to 10 weeks is 40% fewer appointments, and an increase from 6 to 12 weeks is 50% fewer appointments. The usual 6-week treatment interval takes 30 to 40 appointments typically treated in 24 months (105 weeks): it takes on the average: 1 (OBS-Recall), 2-5 (Exam, Records, Consult, Separation, Initial Braces), 18 (active treatments), 1-3 (Emergencies), 2-3 (Deband, Retainer Insertion) and 6-10 (Retention Recall) appointments, totaling 30 to 40 appointments (averaging 35). Unfortunately, only the 18 active treatment appointments are affected by a change in appointment interval and thus for 105 weeks: 8-week intervals require 14 appointments (4 less than 18), 10-week intervals require 13 appointments (7 less), and 12-week intervals require 9 appointments (9 less).
Advantages
Ÿ
Number of appointments:
6-week intervals require 35 appointments, 8-week intervals require 31 (or 11%
less, not 25%), 10-week intervals require 28 (or 20% less, not 40%), and
12-week intervals require 26 (or 26% less, not 50%). Thus, for every 50 patients you now treat per day at 6-week
intervals, you would only need to treat 45 (11% less) at 8-week intervals, 40
(20% less) at 10-week intervals and 37 (26% less) at 12-week intervals.
Ÿ
Chairside Assistant time:
The 24 months of active treatment represents 50% of total treatment chairtime
and thus: 8-week intervals save 6% (50% of 11%); 10-week intervals save 10%;
and, 12-week intervals save 13% of dental assistant time—not as big a savings
as the assumed 25%, 40% or 50%, but still a savings.
Disadvantages
Ÿ
Missed appointments:
Increased appointment intervals quickly increase the number of “run-on”
cases. Patients who miss two
appointments at 6-month intervals get three months behind in treatment; while
12-month interval patients get six month behind; they quickly become out of
control. Run-on cases cause serious
problems including decreased cooperation, a straining of the patient/practice
relationship, and a possible relapse in tooth position. A run-on increases the number of active
cases, with no increase in starts/collections, wasting missed appointments and
assistant time.
Ÿ
Patient cooperation:
If patients don’t wear their elastics or removable appliances they need extra
appointments, which increase the number of appointments calculated above.
Ÿ
There are also certain appliances (C-chains,
Expander adjustments, etc.) that require 1- to 4-week intervals and cannot possibly
be seen at 8- to 12-week intervals, making the above percentage gains slightly
smaller.
Ÿ
In the long run, switching from 6-week to 8-, 10-
or 12-week intervals will reduce the number of appointments by 11% to 26%, not
the 25% to 50% it would seem; most orthodontists find it difficult to justify
an average appointment interval of more than 8 weeks for braces. In the long run, it is best to efficiently
schedule at 8-week intervals; with longer intervals for fixed treatments
requiring less control and shorter intervals for treatments requiring much
control (RPE, finishing appointments, etc.
Ÿ
The longer the appointment interval the greater the
number of run-on patients, which needs control no mater what the appointment
interval.
Dealing with the Run-On Problem
A proven step-wise program to deal with run-on cases
that is mutually satisfying to the patient and practice is detailed below. This program is used to initially clean up
run-on patients and is also used monthly to identify and deal with new run-on
patients, thus wasting less appointment time.
One person is in charge of this program, typically the TC, but not
necessarily.
1.
Identify patients whose
treatment is past its Estimated Completion Date/Time
·
Use the “Run-on Program Control Log” to list
run-on patients alphabetically at first and then chronologically as they occur
in the future.
·
Enter the “Patient’s Name” (Last, First), “Original Estimated
Completion Date” and the “Patient’s Next Appointment Date”
·
Flag the patient’s Tx Chart by writing RO
(for run-on) in bold RED letters near the last chart entry
·
Indicate in the Next Tx part of the Tx Chart, “DR
RO Evaluation & Consult Needed”
·
Each week if possible, for all the run-on patients
with appointments next week, call the patient and tell the responsible
decision-maker to be at the next appointment to discuss “…the completion of
their treatment…”.
2. At the run-on patient’s Next Appointment
·
The doctor reviews the case, determines a realistic
DeBand Date, and notes it in large red letters on the next blank appointment
line on the Tx Chart. The DR may also
write “DeBand Immediately” if fed up with the case.
·
The person in charge of the program has a consult
and discusses the patient’s options using an “Agreement on Disposition of
Orthodontic Treatment” (see below), indicating their choice that the
treatment is:
Ÿ
to be coNTINUED
up to the doctor’s realistic deband date at a specified monthly fee (please
note, you can charge a monthly fee only if you pre-warned them, typically in
their Financial Agreement)
Ÿ
to be terminate
immediately at the next available debanding appointment.
·
The “Agreement on Disposition of Orthodontic
Treatment” is completed and signed, depending on their decision:
Ÿ
The “Run-on Program Control Log” is filled
in including: The “Dr’s
Realistic DeBand Date”, the “Date Pt/Family Sign the Disposition Agreement”,
the “Patient/Family’s
Disposition Decision”, and any “Comments”.
Ÿ
If the patient’s decision is to terminate
treatment, a debanding appointment is made and entered on the control log in
the “Date Debanded” column. Once debanded, the “Dr’s Realistic DeBand Date” column is highlighted.
3. The Patient is treated up to the “Dr’s Realistic Deband Date”
·
The person in charge of this program reviews
the “Run-on Program Control Log”
weekly, focusing on the “Dr’s Realistic DeBand
Date” column for all patients NOT highlighted.
Ÿ
If the realistic date is past, the case is reviewed
with the doctor and the appropriate actions taken.
Ÿ
NOTE! Non-cooperators
must be debanded immediately! They had
their chance and blew it.
Ÿ
If debanded immediately, the bottom half of the “Agreement
on Disposition of Orthodontic Treatment” form is signed and a debanding
appointment is scheduled and entered on the control log in the “Date Debanded” column. Once debanded, the “Date Debanded” column is highlighted.
·
Every patient listed on the “Run-on Program
Control Log” must be debanded and the “Date Debanded” column highlighted within a year of his or her “Original Estimated
Completion Date”!
Patient’s Name: ___________________________________ Phone Number: _______________________
If treatment is to be coNTINUED:
I, the patient, parent or legal guardian of the patient named above hereby agrees to the following program for completion of this patient’s orthodontic treatment.
¨ With patient cooperation, this treatment should be completed by (month)_________ (year)________.
· This patient’s braces will be removed if the treatment is successfully completed.
· Should treatment not be successfully completed by this date, this patient agrees to sign the bottom half of this agreement and terminate treatment at the discretion of the doctor.
¨ There will be a monthly charge of $________ for each month until the case is debanded, starting (month)__________ (year)__________.
_________________________________________ _____________
Patient, Parent or Guardian’s Signature
Date
_________________________________________ _____________
Doctor’s Signature
Date
_________________________________________ _____________
Witness’s Signature
Date
If treatment is to be terminated immediately – Liability Release:
I, the patient, parent or legal guardian of the patient named above hereby approves the premature removal of all orthodontic appliances and the conclusion of active orthodontic treatment.
I acknowledge that I have been informed that this orthodontic treatment is being terminated prematurely.
This practice is hereby absolved of any and all professional responsibility and legal liability at any future date with regards to possible failure or relapse associated with the dental structures of this patient’s teeth, specifically related to alignment of occlusion.
_________________________________________ _____________
Patient, Parent or Guardian’s Signature
Date
_________________________________________ _____________
Use Your Own
Personal Form Original
Doctor’s
Signature
Date
_________________________________________ _____________
Witness’s Signature Date