Wednesday, July 31, 2013

One Year In

I finished my first full year as a “general dentist” at the end of June.  I know it has been MONTHS since my last appearance but I assure you, I am very much alive.  So how are things you ask?


Yea, unfortunately 12 months post residency, my professional life is still meh.  I am much better off than I was last fall (unemployed!), but really it isn’t THAT much better.  I work in two offices.  One is a long-time standing general practice with 2 owner docs and 3 associates.  The other is a Federally Qualified Health Center (FQHC) which caters to low-no income families.  I started in the private office in January and just started in the FQHC in July.  By the way, for you die-hard fans, this is the same FQHC I temped in last fall.  They finally made room for a second dentist and I was invited back for 1.5 days a week. 

The general practice office is still three days a week and if I have anything to do with it, will soon be zero.  Six months have elapsed and I still have a schedule with more holes in it than a moldy piece of Swiss cheese.  The office is predominantly PPO (Over 90% of the patients), and I am paid exclusively on collections (40%).  You see the 40% and think, that ain’t half bad.  Well, as I have found out at a painfully slow pace, the yearly collections in this office is under 90%.  UNDER NINETY PERCENT.  I have never heard of such a poor yield.  The fact that we take all these dogshit PPOs also cripples the ability to charge an even ‘average’ fee.  I’m sorry, but only 400 bucks for four wisdom teeth?  Are you kidding me?

To any readers who are a bit miffed by insurance plans, allow me to summarize (I will likely have an entire post on this in the future).  I won’t deal with HMOs today.  So lots of people have PPO plans.  How do they work?  You usually get them through your employer, who will sign up for a plan to get a specific rate for his/her employees.  You pick your plan, cough up a monthly tab, and get your benefits.  Your average plan will cover 1500-2500 bucks annually.  They generally cover 100% preventative stuff.

So why do they suck?  Because they hamstring the dentist.  PPOs generally raise their fees about 0.5%-1% annually unless the dentist attempts to hardball renegotiate fees.  General inflation in America is 3-4% annually.  Do you see the problem?  The cost for dental materials, staff salary, office supplies, etc all increases with standard inflation.  The PPO does not.  So if you rely heavily on PPOs, you will begin to see a steady decline in office cash flow.  So how do you fix this?  Oh yea, cram as many patients into your schedule as you can.  I don’t care how good you are, you are going to be doing some shoddy dentistry when you are seeing 14+ patients daily (not including hygiene) just to make up for fee’s that you have no control over. 

Now of course the ideal world would be a completely fee for service (FFO) practice.  They do indeed exist, but realistically, most can’t get by without taking SOME insurance.  The key is to LIMIT it.  The inherent system is simply flawed.  Insurance companies are NOT dentists, yet they determine how much we should make.  It is not good. 

But I can dissect this stuff better in a separate post.  The jist of it has been implied.  So this family practice is essentially going under.  Office overhead is in the 70% range, the practice produces 2.5 million a year, yet is still struggling to break even.  So what has this yielded?  The wise and benevolent practice management firm that the owner docs seem to let run the show has suggested that they cut associate dentist compensation.  How they are doing it really doesn’t matter, but it essentially equates to about 60K gross pay for the oldest associate, 30K for my wife and 10K for me.  But hah, I make nothing as it is so what’s the diff.   The only reason I have stayed as long as I have is that the office is generally a positive work environment, I’ve learned a decent amount, I enjoy working with my wife (which bodes well for the future), and I was happy to have a stable work week finally.  But alas, all things tend to change.  I originally planned to stick it out here for at least a year.  Now I’m hoping to be somewhere else by then.  And a big part of me hopes that other place is owned by ME.  OH SNAP!

The real positive of this mess is that it is ignited a fire in my dormant self.  I originally thought I would slug it out as an associate for several years.  Hell no!  We are beginning the process of opening our own practice.  We still haven’t decided if we will buy one out, or start from scratch – but I have begun assembling the Justice League for Dentistry (i.e., my professional team).  This includes a lawyer, CPA, banker, demographics dude, medical contractor, oh my god there are a lot of them.

We are hoping to meet a bunch and find the right fit.  We aren’t rushing into anything, but the process has begun!  I’m pretty damn excited about it too.   Literally just started, but I hope to update as we go along, as this segment of my career will probably be pretty damn interesting for the new dentists coming forth.

So will I go bankrupt?  Make millions?  Die in a freak accident?  Find balance in all things life?  Stay tuned!

So yea, as far as this first year is concerned….



OKOK I know I’m bitching a bit excessively and I truly HAVE become a better dentist despite the lack of dentist-like income.  We aren’t starving or anything either, but the thought of having children or owning a house is much farther away than I would have expected for someone my age.  I still drive a car with no passenger door handle or driver side mirror.  I mean, I don’t need a Maserati or anything, but A/C and a non-ruptured washer fluid line would be nice.  We will get there eventually, but was the five extra years of school + mountain of debt really worth it?  Seeing as a do indeed like being a dentist, I’m still OK with it.  Lots of people make a decent living but absolutely hate their jobs.  I generally enjoy doing what I do at least.  So there’s some positivity!

Ask me again in a decade.

I will hopefully organize some posts about transitioning to ownership in the coming months/years.  I never saw myself as an entrepreneur, but the thought of building something from the ground up, and actually being in charge, and getting to do it MY way sounds so freaking amazing after working for other dudes that do so many things wrong.  Not that I am perfect or anything, but I’m looking forward to giving it the old college try.

Yikes I’m really rambling.  Sorry for the lack of coherence, but that is just how I roll!

Seriously though, I will try to get some thoughtful posts about this transition as it occurs.  Hell, it takes a long time to get rolling anyways so I should be able to find some time.

Good evening.