What doctors can learn from the orthodontist’s office

I took my daughter to the orthodontist last week to get braces.

There’s a lot about the process that seems better than when I was a kid. Mostly, it’s that instead of having to slide brackets around each of your teeth (yishk!) the orthodontist just paints a special glue on the enamel and places the brace on the front of each tooth. Kids get to pick the color of their braces now, introducing some degree of choice (and therefore control) into what amounts to a victimization of one’s oral cavity.

What really stunned me, though, was the way that her orthodontist organized his practice.

I’ve written before about the concept of “Patient-Centered Medical Homes” (PCMH), a high-minded concept in which patients see a doctor or her associates whenever necessary, and all information is seamlessly inside a electronic medical record so any and all providers are able to deliver timely, safe, effective, high-quality care.

It’s an idea that is central to health care reform, and seen as a way in which we can contain costs. (Of course one of the big problems with this concept is that patients often don’t understand the name. Survey data shows that there are loads of misconceptions about what a PCMH actually is. Here is one funny look at this phenomenon.)

My daughter’s orthodontist is part of a three person practice. But for each orthodontist, there are three hygienist/techs and at least one office staff member handling billing, care coordination, and administrative issues like computers.

This sounds pretty personnel-heavy, but let me assure you there was constant motion and therefore constant ‘productivity.’

In the hour that it took for my daughter to have her braces applied, there were four different patients seen in the chair next to her, by three different techs and two of the orthodontists.

The examining suite was arranged with eight chairs in a semicircle, and each chair had a computer screen next to it so that the patient’s parents could see their kids’ xrays, projections of what their jaws/teeth would look like during and after treatment, and get educational material. Of course, the techs and orthodontists used the system for entering patient data as well.

In the center of the circle, tech/hygienists were troubleshooting, preparing trays for subsequent patients, discussing aspects of care, etc.

The orthodontists (two present while I was there) literally sat on office chairs and swiveled from patient to patient–washing up copiously between each encounter, and leaving plenty of time to communicate with parents, and work phone calls in between patients.

It was a tour de force.

I was overwhelmed by the efficiency of it all, the professional nature of the encounter(s), and my daughter entering a rite of passage (and how brave she was!) in no particular order.

How much does it cost?

Well, like health insurance, our employee-benefit dental insurance defrayed a significant portion of the upfront cost. What our insurance didn’t cover, we could have financed. We chose to pay the remainder in a lump sum so as not to incur interest on the debt.

But like a capitation model, we’ve payed for the treatment. Under the contract we’ve signed, our daughter can visit the orthodontist 12 times, 24 times or more, however many it takes to get her teeth straight. I’m certain that at a practice like this one they know their business well enough that even with some unexpected hiccups, they will make money on most patients in the long run.

And I’m ok with that. They are providing real value for our money. It goes beyond the “product.” It encompasses the feeling that I got by participating in my daughter’s care and seeing how the operation worked. Literally.

Our experience there made me wonder why medicine can’t be practiced this way.

Medicine is too complicated. Our costs are too variable. Our practice flows are less predictable. We’re not just focusing on one part of the body.

But what’s to stop us from, say, asking our patients with diabetes to come to group visits? They could be seen en masse for education and testing, and see the doctor for quick individual consultations about medication adjustment or the need for further consultation. All the providers (docs, nurses, medical assistants, physician assistants, nurse practitioners, dietitians, etc.) could be ‘practicing at the top of our licenses.’

At the orthodontist’s office, the hygienists and techs all were involved in lab work, preparation, and direct patient care. No one’s talents were going to waste by locking into one repetitive job description. I spoke with one hygienist, and she told me that she enjoyed the different roles in her job. And she felt empowered to make change or to let the orthodontists know if something wasn’t working well. All in all, it seemed a pleasant work place with a real team atmosphere.

I guess seeing it first hand makes me realize that achieving a medical home model can be done in primary care. We just need our medical homes to be more like our orthodontic homes.

Just ask my daughter. Luckily for her, with modern methods, there’s no need for headgear anymore.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • Anonymous

    What doctors can learn from the orthodontist’s office:

    Balance billing.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      And complete rejection of insurance participation

  • http://twitter.com/DarrellWhite Darrell White

    Nice post! What kind of a doc are you Dr. Schumann? Your post sounds like one written by a Family Practitioner or an Internist. Please forgive me if I am incorrect, but I’ll proceed as it that’s the case.

    How do you feel about the income inequality between primary care docs and orthodontists? Are you aware of the income earned by an orthodontist in the above-described scenario? It’s quite impressive, as it deserves to be. High quality care coupled with a very pleasant experience and an obvious emphasis on the patient/family, all layered on top of a world class business system meant to maximize revenue and profit. Sounds like, at least as far as orthodontists go, you’re pretty good with that. For the record, so am I. 

    Although your insurance covered a handsome part of the cost it did not cover all of it, and the orthodontist balance-billed you for the remainder. You almost certainly could have found a doc who would have accepted your insurance payment as payment in full, but you were free to choose what you felt was a better value: better care, a better experience, at a price point you chose. Wouldn’t it be cool if your patients could do that, too? Think it would prompt you, or your competitor, to devise a system like your daughter’s orthodontist? 

    I’m an ophthalmologist. I practice in a setting that is very similar to what you describe, albeit without the ability to balance bill. And yet here, and elsewhere, the fact that we are extremely efficient while providing a very nice experience, and are conscious of both top and bottom lines, brings scorn and derision. I am somehow a lesser doc, the more efficient and fast I become the lesser doc I am accused of being.

    How, Sir, will we as a profession arrive at the pinnacle of orthodontia if those among us are the objects of scorn when we try? When we are held up as targets to be brought down, rather than goals to which others should aspire? Why must it be necessary to bring down those who would provide options for all to explore? 

    Despite the fact that my setting, process and philosophy is the same, why am “I” considered a lesser professional than your daughter’s orthodontist?

    • Anonymous

      ‘why am “I” considered a lesser professional than your daughter’s orthodontist?’

      Leaving aside individual physicians and dentists, maybe the point it that the orthodontic society has not worked long and hard with the ADA to increase the pay of its members at the expense of general practice dentists.

      • http://twitter.com/DarrellWhite Darrell White

        Why is it always “at the expense of” any other doctor or kind of doctor? Why is it so poorly understood, or so incompletely known, or so routinely ignored that for many medical specialists payment per unit of service has gone down, not up, since the initiation of RBRVS? Why is it so important for those who feel they are underpaid to drag down the pay of those who they feel are not? Why is it assumed that it is a zero-sum game? Why do you persist in professional cannibalism? 

        My pay per service, at least those services that I do not bill in exactly the same way as a primary care doc, has declined by ~60% without taking into account inflation since 1990. Although I think a compelling case can be made that some services were over-valued and over-paid then, we have long since gone past what any reasonable observer would consider a fair trading or market value. Indeed, patients have said many times in all kinds of surveys that they would pay more out of pocket for standard cataract surgery, and many do pay much more for extra uncovered aspects such as presbyopia correction.

        That is mostly beside the point of my comment, and mostly in response to your comment. I ask again, if I have done everything that I can to replicate the orthodontists office, system, and service (except, sadly, balance bill), extending myself and providing more care/hour than other doctors of all stripes, why am I considered less professional because I do it in ophthalmology? Less professional than an orthodontist? 

        I shudder to think of the reaction of organized Family Medicine should Dr. Schumann ever try.

        • Anonymous

          There are two factors here: the size of the pie and how the pie is divided up .

          The size of the pie is determined by the conversion factor. This affects all docs equally.

          How the pie is divided up is determined by the RUV. The proceduralists have worked this to their advantage for the last twenty years. The pay gap between proceduralists and non-proceduralists has widened, and continues to widen, each year since the RUV was introduced.

          Each year, on a per capita basis, the proceduralists have gotten a little bit larger piece of pie, at the expense of the non-proceduralists. Those who do nothing but procedures (radiologists, etc.) have benefitted the most from this system.

          This is a profession-wide problem, and I do not consider you less professional than the orthodontist. The original post was such a comparison of apples and oranges that I found it pretty meaningless.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    “…..I guess seeing it first hand makes me realize that achieving a medical
    home model can be done in primary care. We just need our medical homes
    to be more like our orthodontic homes…..”

    Be careful what you wish for.

  • http://www.facebook.com/people/Frank-Lehman/100002241640186 Frank Lehman

    Dr. Schuman said:  “I guess seeing it first hand makes me realize that achieving a medical home model can be done in primary care.”  What I do not understand is why you want to limit your comments to “primary care.”  I would think that all physicians would benefit from a good business model, improved utilization of personnel, etc.

  • Anonymous

    Pretty simple, Dr. Schumann.  Orthodontia, as I discovered from my son’s experience, is amenable to Fordism–a simple set of predictable operations that can be managed by an assembly line, which in turn makes possible the  division of labor and efficiency.  Orthodontists have few diagnostic difficulties.  They rarely have to think deeply and seriously about how the patient’s mutlifaceted medical problems will affect—straightening a few teeth. 
    If you want an orthodontia-type practice, perhaps you might like allergy or, better yet, botox medicine- with balance billing of course. Might a suggest a botox-home practice?

  • http://pulse.yahoo.com/_6C65YWGCC7P5C6CGMMBK7VMFXE JenniferL

    Oh, there is much to be learned:

    No insurance.

    No ObamaCare.

    No Medicaid.

    No managed care.

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    In my high school class, four students became physicians. One became an orthodontist.

    The orthodontist is doing far, FAR better economically than the doctors. Built a palace of an office.Beautiful house. Private school for his kids.

    Good for him. I sure can’t afford in primary care, to do what he did as an orthodontist.

    And hey, I know many docs who, in fact, did what the orthodontist did. Retainer practices. They get slammed as sellouts. Double standard. And you wonder why doctors get an attitude sometimes.

  • Anonymous

    As a patient, I have one observation – group visits are for support groups not for physician visits. I value my twice-yearly appointments with my family doctor. I expect my privacy to be respected and my health issues to be addressed within that context, not shared with other patients that I have not chosen.