The Economic Realities of
Providing Dental Hygiene ServicesBy Michael Perry, D.D.S.
When I started practice in 1979, the hygienist in the practice I associated with was salaried at $14.50 per hour with no benefits. A little research showed we were charging $39 for a 1 hour dental prophylaxis, $18 for 4 bite wing x-rays, $54 for periodontal maintenance, and $90 for 1 hour of scaling and root planing. In those days our hygiene department emphasized recall rather than perio. Even though the array of procedures would vary, it seems reasonable to state that her average 8 hour day included 5 prophys, 4 sets of bite wings, 1 perio maintenance, 1 hour of SRP, and one cancellation/no-show. If she arrived 15 minutes before work and left 15 minutes after, she would earn a total compensation of $123 per day while producing $411-- a compensation to production ratio of 1 to 3.3. (195 + 72 + 54 + 90 = 411).
In the practices I’m coaching today, I’d estimate the average total daily compensation for hygienists (including benefits) is $450 with an average daily production of about $800 -- a ratio of 1 to 1.9.
Twice during my early years in the practice, we had our hygienist decide to move out of the area. Each time our business manager interviewed several prospects before introducing the ones she deemed the best and brightest to us doctors for the final decisions. Each time she provided us with her opinion about the tradeoffs between choosing a less experienced, lower salaried hygienist and a more experienced person whom we’d have to pay more. I recall the overall skills of each of those who worked for us to be very good if not excellent.
Today dentists in many areas face several thousands of dollars in fees to employment agencies if not more in “signing bonuses” to interview and hire a single prospect. Experience counts for little if anything when negotiating compensation.
It has become common for dentists to spend a great deal of time commiserating with each other about the reasons for this unfortunate evolution in the marketplace. The urge to place blame has become irresistible as frustrations around the issue have reached a level unprecedented in my experience as a practitioner or consultant. Given that prices for dental services and employee compensation are subject to the same laws of inflation, and supply and demand that affect other service industries, what has gone wrong and why?
2
My accountant tells me that the most recognized indicator of inflation, the “consumer price index” (CPI) has averaged 4.15% over the past 23 years. He calculated this would mean that $1.00 in 1979 would be worth $3.66 today. This means that the $123 daily compensation for my hygienist in 1979 would be worth $450.18 today. Hmmm.
The opinion I draw from this exercise is that if hygienists’ compensation was fair and adequate in 1979, its fair and adequate today. The problem is on the production side of the equation. Why is it that production has not kept pace? My theory? Of the multitude of factors effecting the economics of dental hygiene practice in the past 2 decades, I feel two have been particularly significant: 1) the downward control of fees by third parties and 2) the “giving away” of periodontal treatment by clinicians. The “paradigms” dentists and hygienists have built around these 2 factors have made them very resistant to change.
Using the 23 year average CPI 0f 4.15 % presented earlier, if $39 for a dental prophylaxis was a usual, customary, and reasonable fee in 1979, then $143 would be the proper UCR fee today (try that next time you submit your fees to Delta). The UCR fees for 4 bite wings, perio maintenance, and 1 hour of SRP would be $66, $198, and $329 respectively. Rather than setting fees based upon the cost of practice, dentists have followed the lead of third parties in deciding what to charge for these procedures.
Some estimate the portion of American adults with periodontal disease at 75% (some even higher). In my experience with clients, the average portion of patients receiving “cleanings” in the daily hygiene schedule is about 60%. These percentages indicate that either a large number of patients are not receiving needed periodontal treatment or they are receiving needed periodontal treatment free of charge along with their prophy procedure.
My opinion? Dental hygienists are trained, as a matter of proper care and ethics, to thoroughly debride teeth of toxic deposits. It is, if you will, a tenet of their profession. In my experience, most find it personally unacceptable to leave deposit behind if they are able to remove it in their allotted appointment time.3
The CDT-3 states that a dental prophylaxis is the scaling and polish of supra gingival tooth structure (doesn’t even include OHI). My sense is that most hygienists would find it outside of their personal sense of integrity to limit their treatment for prophy patients to this definition. So the patient who, for whatever reason, has not accepted periodontal treatment, receives it anyway.
Dental hygiene consulting companies have emerged in the past 2 decades that (for 5 figures) will train teams how to better communicate with patients about periodontal treatment. These companies are thriving, in my opinion, because most dentists and hygienists are not able to move beyond these powerful paradigms that control their behavior around the delivery of dental hygiene services. It is also my opinion that, from an economic standpoint, the hygiene department in many general practices has become dysfunctional--no longer making economic sense as a viable business enterprise.
May 1, 2002
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