Dental  Care  Delivery  in  Canada  A    Profession  and  a  Big  Business  

 Any  lessons  for  Veterinary  Medicine  ?  

   

Canadian  Animal  Health  Institute  Hockley  Valley  Resort  

Dr.  Brian  Barrett  June  8,  2016  

 

*  Dr.  Brian  D.  Barrett,  DDS,  FACD,FICD,FPFA,FADI  *  Executive  Director  Dental  Association  of  PEI  *  National  Dental  Advisor  Veterans  Affairs  Canada  *  Consultant  for  Medavie  Blue  Cross,  RCMP,  WCB  *  Over  35  years  in  private  practice  –  Economics  committees,  Fee  guide  

Committees  ,  National  Committees  on  Dental  Benefits.  Ethics,  Practice  Management  

*  Son  of  a  dentist  –  50  years  of  dental  practice  involvement  *  Father  of  a  VET  !  *  Poppy  to  4  grandsons.        

Who  is  this  guy?    Dr.  Liz  Barrett’s  Dad  

Dentistry    -­‐    Veterinary  Medicine  One  of  these  things  is  not  exactly  like  the  

other  one  

Dr.  Elizabeth  Barrett,  DVM,  MS,  DACVS,  Board  Certified  Equine  Surgeon  Hagyard  Equine  Medical  Institute  –  Lexington    KY.  

*  1  Species    (People  )          vs          Many  species  (  Animals)  *  One  specific  aspect  of  health      vs        All    aspects    *  Patients  can  talk                vs            Not  usually    *  Direct    health  information        vs        Through    owner  *  Dental  Insurance            vs            Pet  Insurance    *  Pretty  well  have  to  fix  it            vs                Euthanasia    *  Long  term  patients                vs          Hopefully  keep  owners  *  Diet  prevent    tooth  decay          vs              Nutrition    for    life                    

Apples  and  Pumpkins  

*  Vast  majority  of  visits  to  vet  clinic  are  for  sickness  or  injury  –  treatment  for  emergency  care  or  disease.  

*  Vast  majority  of  visits  to  dental  clinic  today  are  for  preventive  services  /    recall  examinations  

*  Dental  Health  is  very  responsive  to  prevention.  *  However  at  one  time  it  was  the  same  as  vets  –  

emergencies,  tooth  aches  ,  infections,  pain.  

Clinical  Practice  Differences  

*  If  the  lessons  we  learned  and  circumstances  are  such  maybe  veterinary  medicine  can  improve  their  practice  incomes  by  learning  by  our  case  –  or  our  mistakes.  *  There  are  business  models  that  apply  to  any  healthcare  practice  that  can  be  utilized.    *  Same  factors  of  “busyness”  and  “productivity”  apply    *  Times  are  a  changing  however  –  some  change  may  not  help.    Supply  and  demand  like  anything  else.    *     -­‐  SO  

Maybe  there  are  lessons  to  be  learned  –  ?????  

*  Delivery  of  dental  care  has  changed  a  lot  in  last  50-­‐100  years  –  not  for  income  though.  *  We  could  not  see  all  patients  who  needed  and  wanted  treatment.    *  There  was  a  shortage  of  dentists  *  All  were  busy  although  some  had  to  moonlight  in  other  professions.  

                                                       

How  and  Why  Dentistry  got  to  where  it  is  in  20  minutes  or  less  

*  Dentist  alone  –  stand  up  by  the  chair  –  my  Dad  in  1952.  *  Dentist  did  all  the  work  himself,  time  consuming,    tiring  and  poor  utilization  of  the  training  they  received.  *  BUT  -­‐  Salaries  were  very  low  percentage  of  the  expenses  in  the  office  and  net  income  was  almost  60%  of  gross.  *  Hit  the  limit  on  procedures  and  income  very  quickly.  Only  increase  in  take  home  pay  is  speed  –  do  more  in  same  time.  

One  man  show  -­‐      1800  –  1950’s    

*  Chair-­‐side  assistants:    Trained  to  help  dentist,  pass  instruments,  mix  materials,  suction,  seat  patient,  sterilize  –  any  task  that  could  be  taught  and  done  legally  by  non  dentist.  No  standard  training  needed.  *  Intraoral  assistants  –  do  some  treatment  on  the  patient,  polish  teeth,  x-­‐rays,  have  to  be  certified.  *  Dental  Hygienist  –  advanced  training  –  more  duties  *  Expanded  Duty  Hygienist  /  Dental  Therapist  /  Treat  alone  for  specific  services.  

Additional    new    staff    1950’s  to  1990’s      

*  Reclining  dental  chair  and  operators  stools  *  High  Speed  Hand  piece  –  no  more  smoke  *  Dental  Materials  all  improved    *  Impressions  ,  filling  materials,  anesthetic.    *  Suction  and  chairside  –  no  spitting  *  Better  for  operators  and  patients  *  ALL  made  treatment  times  shorter  and  more  efficient.  

Changes  in  Equipment  and  Materials      

*  US  data  but  probably  close  in  Canada  and  here  we  have  a  much  higher  percentage  of  people  going  to  dentist.      *  In  1950’s  almost  half  appointments  were  amalgam  fillings  and  40%  exams  and  cleanings.  *  By  2005  -­‐  60%  diagnostic  and  20%  preventive  and  all  other  procedures  making  up  the  balance.  *  It  may  come  as  no  surprise  that  a  lot  of  the  treatment  can  be  performed  by  auxiliary  staff  and  the  supervised  income  can  be  3  to  4  times  what  they  are  paid.  

Changes  in  mix  of  procedures  1950  –  20oo  

*  AND  as  a  reminder  –  most  was  not  done  to  do  so.  *  It  was  almost  as  if  there  was  some  sort  of  magic.  *  Insurance  ,  patients,  education,  equipment,  staff  *  The  process  however  started  of  late  to  slow  down.  *  Again  –  many  factors  but  it  probably  could  have  been  expected.  *  Fee  guides  were  developed  for  years  but  NOW  –  changes  in  process  and  weighted  fees.  *  Entire  process  is  very  complex  AND  vulnerable.  

All  sorts  of  things  came  together  to  cause    incomes    to      rise.  

*  Fee  “GUIDES”    not  schedules  =  you  charge  what  you  want  *  Big  economic  surveys,  analysis,  cost,  income.    *  Auxiliary  services  –  same  fee  no  matter  who  delivers  the  

treatment  –  others  believe  it  should  be  lower.  *  Free  market  =  no  fee  guide  at  all    -­‐  Alberta  –  Quebec  have  

highest  fees  in  Canada  Fee  guides  also  evolved  over  the  same  time.  *  Have  to  have  fair  fees  that  gives  the  dentist  an  income  

considering  their  investment  in  time  and  money,  for  education  and  practice  equal  to  a  “like  professional”  *  Have  to  be  very  careful  to  assure  the  fees  are  a  guide  and  

not    a  schedule  to  protect  the  public  and  be  in  line  with  Competition    Bureau.  

Development  of    Fees  for  services  More  than  per  hour  rates  

*  Everyone  was  happy  –  great  incomes  –  lots  of  work  *  Many  have  much  of  their  dental  treatment  paid  for  *  More  people  are  taking  better  care  of  their  teeth  *  Professional  Associations  worked  very  hard  to  make  sure  dentistry  was  a  success  and  patients  were  well  taken  care  of  .  *   Education  –  Lobbying    Dentists,  Public,  Government,  carriers.  *  Expensive  and  a  lot  of  work  by  a  lot  of  people  *  HOWEVER  –  times  are  changing  and  more  will  be  needed  

The  last  40  years  have  probably  been  the  Golden  years  

*  Depending  on  type  of  practice  and  time  working  *  Want  to  increase  public  awareness  for  prevention  and  importance  or  regular  care.  *  Preventive  annual  visits  VS  emergency  care    *  Want  to  improve  the  professional  image  –  increase  respect  for  what  they  do  and  what  they  know.    *  Hammer  fix.    *  Associations  main  reason  for  being  is  to  improve  life    *  What  did  dentistry  do  to  address  these  issues  .  *  Price  of  individual  procedures  can  depress  them  all  

Veterinary  Practice  –  is  there  anything  that  can  be  learned?  

*  Developed  and  paid  for  by  Associations  *  To  encourage  preventive  side  VS  emergency  tx  only  *  Wellness  rather  than  sickness,  increase  visits  to  dentist,  importance  of  dentist  being  the  leader.  *  Best  practices  -­‐-­‐Diet,  sugar  reduction,  fluoride  etc.  *  Had  to  make  patients  buy  into  prevention  totally.  *  And  =  pay  for  the  service  annually  or  semi  annually.  *  It  works  well  –  requires  a  lot  of  administration  and  oversight    –  tremendous  asset  while  working  and  to  sell  on  retirement.  

*  Respect  –  Value  of  service  –  have  to  be  good  and  available  and  honest.  *  Unique  body  of  knowledge  –  expensive  to  get  education  –  working  life  is  shorter.  *  Have  to  make  people  appreciate  the  costs  and  responsibilities  of    operating  a  clinic.  *  Medicare  gives  people  weird  perception  of  costs  *  Vets  and  Dentists  =  hospitals  –  all  aspects  *  Only  the  professions  have  diagnosis  as  a  restricted  act  and  that  is  what  the  fees  are  for  =  You  really  get  paid  for  what  you  know  even  more  so  than  what  you  do  

Professional  services  are  Expensive  and  so  they  should  be.  

*  Most  effective  and  acceptable  on  improving  health  and  professionalism  .  *  Can  have  various  promotions  =  co  paid  by  health  product  companies.  *  PR  with  government  and  media  =  same  message.  *  Have  to  show  concern  for  the  public.    *  Increase  participation  and  perceptions  .  *  All  intended  for  the  right  reasons  =  good  health  –  PLUS  –  continue  to  maintain  and  increase  incomes.  

Expensive  to  get  Information  to  the  public  at  large  -­‐  Associations  

*  It  takes  a  long  time  to  change  perceptions  and  habits  of  the  public  –  has  to  be  repeated  in  office.  *  Even  when  they  know  what  is  good  for  them    *  Important  to  have  a  constant  message  and  repeated  by  all  players  until  EVERYONE  knows  it  by  heart.  *  Then  when  demand  is  there  =  make  it  affordable.  *  Organized  professional  joint  efforts  -­‐    Part  for  the  industry  to  do  the  additional  education  and  promotion.  *  Trust  your  VET/Dentist    for  your  Animal’s/Children’s  continuing  health.  

50  years  –  Joint  effort  

*  All  these  things  together  –  increasing  awareness  –  Economic  growth.    *  BUT  –  as  people  are  taken  to  a  higher  level  of  health  the  treatment  changes  –  more  high  end.    *  More  Esthetic  treatment  –  looking  good    *  Absolutely  need  almost  a  continuing  supply  of  new  patients  –  and  to  have  stability  a  large  number  of  recall  patients.      *  You  need  good  education  programs  to  continue  to  attract  them  –  BUT  AT  SOME  POINT  –  ratios  change  and  then  ?  

Those  are  some  of  the  things  that    came  together  to  get  those  results.  

*  Badly  affected  of  late  =  trust  is  being  lost.  *  Overtreatment-­‐  -­‐    overcharging  *  Business  or  Health  Profession  –  one  of  the  two  balance  act.  *  Costs  are  huge  –  overhead  can  be  70-­‐80%    *  Dentist  :    Population  ratios  are  falling  quickly  *  So  after  years  of  expansion  =  reduction  in  incomes  is  coming.      

Down  30%  last  10  years  in  the  US.  *  One  has  to  watch  costs  as  much  or  more  than  increased  gross  

income    

Trust  –  Vital  and  Fragile  Dentistry  has  taken  some  hits  

*  In  order  to  assure  increased  success.  *  Surgical  and  treatment  based  –  change  to  prevention  *  See  ads  on  TV  for  supplements,  drugs,  other  preventive  treatments,  older  animals,    *  Small  animals  –  people  want  them  to  stay  healthy  *  Large  animals  -­‐    owners  want  to  protect  investment  *  GP  vet  is  a  quarterback  –  Diagnosis  -­‐  referrals,  treatment  coordination,  etc  *  Technicians  Increase  their  duties  in  the  clinic.  

Veterinary    Practice  ?  Maybe  the  time  could  be  NOW.  

*  Actually  need  to  have  more  patients  than  you  can  see  –  or  there  is  a  chance  to  create  a  demand.  *  Has  to  be  legal  to  have  techs  do  additional  services.  *  Have  to  make  people  want  to  keep  animals  healthy  rather  than  wait  until  they  are  sick.  *  May  actually  have  to  adjust  fees  down  in  some  cases  to  attract  business.  *  Need  a  visible,  talked  about  prescence  with  trust  *  Long  term  activity  –  depending  on  demographics  may  not  result  in  any  increase.  *  Medicine  –  going  back  to  fee  for  service  .  

BUT  –  in  order  to  implement  these  type  of  practices  

   Schalk,  A.  F.  "Veterinary  Preventive  Medicine,"  Iowa  State  University  Veterinarian:  Vol.  6:  Iss.  4,  Article  2.    1944.  *     *  For  centuries  the  clinical  and  "curative"  conception  of  medicine  has  dominated  

medical  thought  and  procedure,  practically  to  the  exclusion  of  all  other  phases  of  this  great  art  and  science.  It  has  been  so  uppermost  in  the  minds  of  most  medical  authorities  until  quite  recently  that  they  were  and  many  are  today  almost  entirely  oblivious  to  other  potent  measures  and  practices  that  so  materially  contribute  to  the  well-­‐being  of  the  animal  organism.  Thus  our  domain  of  service  has  been  rather  strictly  confined  to  diagnosing,  prescribing  and  administering  to  animals  in  which  a  pathological  state  actually  exists.  At  the  same  time  the  major  problems  of  prevention,  control,  suppression,  and  possible  eradication  of  disease  have  been  blissfully  ignored.  This  condition  still  exists  in  spite  of  the  fact  that  more  than  three-­‐quarters  of  a  century  of  scientific  research  with  its  wealth  of  dependable  data  and  derived  fundamental  principles  has  established  a  sound  basis  for  the  field  of  Veterinary  Preventive  Medicine.  Today  this  should  be  as  accurate  a  field  of  scientific  endeavor  as  that  of  any  other  branch  of  veterinary  medicine.  Yet  regrettably,  the  fact  remains  that  applied  scientific  hygiene  and  preventive  medicine  have  not  kept  abreast  with  the  needs  and  trends  of  our  profession.  

*  The  practicability  and  economics  of  veterinary  preventive  medicine.  A  report  of  a  three-­‐year  scheme  by  the  Mid-­‐West  Division  of  the  B.  V.  A  

*  Veterinary  Record  1969      84:2  26-­‐41doi:10.1136/vr.84.2.26  

This  is  not  new  

*  Need  a  booking  schedule  that  makes  sure  most  time  is  utilized  effectively  –  no  standing  around.  *  Travel  time  can  kill  practices  –  losing  money  on  top  of  no  income  as  expenses  continue.  *  ANY  training  or  therapy  that  can  be  done  by  a  tech  or  even  students  that  cost-­‐  less  than  the  vet  is  extra  income  –  as  long  as  the  vet  is  busy  as  well.  *  In  office  promotion  of  additives,  vitamins,  drugs  etc.  *  Is  there  any  chance  to  increase  attendance  for  annual  tests  /  vaccines  /  preventive  therapy  /  diet  /  etc.?  

Scheduling  /  Division  of  labor  

*  People  can  always  afford  what  they  want    *  These  could  be  the  Golden  years  for  Veterinarians  *  Income,  Insurance,  Promotion,  prevention  *  All  come  together  at  the  right  time  –  perfect.  *  It  is  vital  to  have  a  large  group  of  patients  who  are  committed  to  an  ongoing  relationship  with  the  vet  and  the  clinic.      *  Advertising    –  not  found  to  be  all  that  effective  for  individual  practices  and  it’s  expensive.  *  Word  of  mouth  in  any  business  or  profession  can  make  or  break  you.  

Research  –  Validation  of  Promotions  

*  Well  –  dental  insurance  made  a  huge  difference  –  but  then  the  carriers  can  exert  control  over  the  profession.    *  Auxiliaries    get  independent    -­‐  want  more  =  respect  ,  money  ,  autonomy,  expanded  scope  *  Work  is  limited  -­‐  only  so  many  patients  –  only  so  many  pets  –  more  vets/dentists  every  year.  *  Protect  the  profession  and  the  public  –TRUST  *  New  management  information  is  all  about  cutting  costs  =  gross  and  net  may  have  peaked  *  BEST  ADVICE  –  treat  as  you  would  want  and  all  will  be  fine.    Any  business  is  tough  –  next  generations  ?  

 May  have  to  be  careful  what  was  

wished  and  worked  for  .  

*  Internet  –  Facebook,  High  tech  Web  sites,  interactive  *  Easy  appointments  and  access  *  Information  is  readily  available  and  90%  is  wrong.  *  “Don’t  believe  all  that  you  read  on  the  internet”  Abraham  Lincoln  ,  1864  *  Maybe  others  will  spread  the  news.  *  Any  promotion  is  great.  

New  ways  to  promote    Practice  and  Products  

*  Contact  me  at    DR.DAPEI  @  gmail.com  

Questions    ?  Complaints  –  call  someone  else