JCO Interviews Dean C. Bellavia, PhD, on Practice Management

DR. GOTTLIEB What do you consider to be the ideal one-man practice?

DR. BELLAVIA I think the ideal one-man practice has about 300 starts. You must work 40 weeks a year, four days a week, with seven staff. You need about 2,800 square feet of office space, and you must be well organized, with a high level of scheduling sophistication. If your average fee is $2,200, you'll probably gross around $550,000 a year.

DR. GOTTLIEB I am not finding that. It surprises me how relatively low gross income is in relation to starts and what orthodontists say their fee is.

DR. BELLAVIA That's because the average orthodontist's fee is about 15-20% less than he thinks it is. If he says it is $2,500,I find that it is closer to $2,100, because he forgets about all the discounts and free treatment. I also find that the number of starts is usually 20-30% less than the doctor thinks it is. It also depends on whether the practice believes in early treatment or late treatment starts. Those who start treatment earlier have about 50% Phase 1/Limited Starts and 50% Full Starts. An early start practice with 200 starts, whose Full Start fee is $2,200 and whose Phase 1/Limited fee is $1,400, would generate $2,200 X 100 starts plus $1,400 X 100 starts, or $360,000 per year. A late-start practice would generate $2,200 X 150 starts plus $1,400 X 50 starts, or $400,000 per year.

DR. GOTTLIEB How do you decide on the size of the staff needed for a certain number of starts?

DR. BELLAVIA The doctor's level of productivity determines the schedule, and the schedule determines the number of starts and the number of staff.

DR. GOTTLIEB There appears to be great variation in the number of staff different practices need for the same number of active patients.

DR. BELLAVIA The number of active patients is not the proper determining factor, except perhaps to tell you whether you are out of control or not. The proper determinant is the number of starts and the type of starts-- Full or Phase 1/Limited. You can base income, staff, everything on starts.

DR. GOTTLIEB That's the whole staff, and not just operatory staff?

DR. BELLAVIA The entire staff, exactly.

DR. GOTTLIEB How many employees does the average practice need?

DR. BELLAVIA You don't count employees-- you establish positions, and you determine how much of an employee you need in each position. For example, a 250-to-300-start a-year practice

working 40 hours a week would probably have one bookkeeper working 20-30 hours a week. That'stwo-thirds of a bookkeeper. Depending on how good your communications are, you'll need somebody working 10-15 hours a week doing letters and communications. So let's say we have two-thirds of a bookkeeper and one-third of a secretary. That's one whole person. If you get a bookkeeper who types, you've got a whole person there. Then you need a full-time receptionist, because you are probably dealing with 60-70 patients a day. That's two people. You will need two-thirds of a TC or treatment coordinator, who is also one-third of a receptionist aide, to help the receptionist during high-volume time. So that's three clerical staff. If you're taking your own records and have an average level of delegation, you will need three chairside assistants, one-half of a records tech, and half a lab tech (if you do just retainers). If a lot of lab work is done, there might be another lab technician. Thus, we're talking about seven or eight people, which is typical for a 250-to-300-start practice.

DR. GOTTLIEB What about the average practice that might start half that many patients?

DR. BELLAVIA The average practice would need just half. The average 150-start practice would need one-half a receptionist, one-half a bookkeeper/secretary, one-half a TC, one-quarter a records tech, one and three-quarters DAs, and one-quarter to three-quarters a lab tech. This gives you three to four staff. The TC would probably be half a DA, but she would have to be a special personality type.

DR. GOTTLIEB The TC has to be a special person altogether.

DR. BELLAVIA If you get the wrong person in that position, or if you don't train and monitor her,she can hurt the practice. But if you get the right person in that position, you can't believe how happy the people are. Our TCs have the patients totally involved. It is the patient's exam, for instance; the patient is not the object of the exam. The patient is the important person, and they treat him that way. The mother usually just sits there with a big grin on her face, so proud of her child, and getting so much joy out of the whole experience. The motivation and attitude of the patient is also much better.

DR. GOTTLIEB How much time should the doctor spend with the patient up to the point of starting treatment?

DR. BELLAVIA He should spend about 10 to 15 minutes on the exam. That's all he really needs, except in a very complicated case. A well-thought-out, organized, comprehensive examination takes 5 to 10 minutes, and still leaves time for the usual chitchat and friendliness. The doctor dictates to the TC, and she writes it all down. More than 10 or 15 minutes, I find, is a waste of time. At the treatment conference (the case presentation), the TCs become so good after a while that there are no questions for the doctor to answer. But the doctor should emphasize cooperation, goals of treatment, and any possible problems. I think it shows respect for the patient to go in there and at least say hello, even if it's just, "Mrs. Jones, it's great seeing you again. We really love to have Johnny here and we're going to do a great job together. I'll be looking forward to seeing you in a few weeks. Thank you for selecting our practice for your orthodontic treatment".

DR. GOTTLIEB The explanation of the diagnosis and treatment plan is done by the TC?

DR. BELLAVIA Right. The doctor may just summarize certain things.

DR. GOTTLIEB A great many orthodontists refuse to accept that.

DR. BELLAVIA Especially those who have been practicing for 15 or more years, and it's hard to change. But once they change, they wonder why they ever did it any other way.

DR. GOTTLIEB How do you determine the right personality type for the TC position?

DR. BELLAVIA My clients use a personality profile when hiring their staff. It's just one factor in hiring, but since the personality of the TC is about 60% of her job, it's very important in hiring her.Very rarely do you find somebody who is a good bookkeeper and a good TC. They tend to be opposite types, and, as the practice grows, they tend to go in the direction they like best.

DR. GOTTLIEB What do you look for in hiring staff members?

DR. BELLAVIA I think the number one criterion is to decide what you want. If you need a chairside assistant, you look for a chairside assistant. If you need a receptionist, you look for a receptionist. If you need a TC, you look for a TC. Of course, it depends on the size of the practice. If you have two employees in your practice, they'd better know how to do everything. If you've got a 300-start practice with a staff of seven, the receptionist is never going to be in the treatment area, so you look for a receptionist, not a treatment person. Most orthodontists think that clerical staff should be able to treat at the chair. This is a fallacy. There are two types of people in a practice-- clerical and clinical. In answer to my questionnaires, all the clinical staff say they really don't want to do clerical work, and the clerical staff say they don't want to do clinical work. After you decide what kind of person you want, make sure they want to work the number of hours a week the job calls for. You can't hire a part-time person with the idea that she's going to work full-time, because it may never happen.

DR. GOTTLIEB Is newspaper advertising the best way to find people?

DR. BELLAVIA I'd rank newspaper advertising first, friends of present staff second, patients and their parents third, business schools or dental assistant schools fourth, and agencies last.

DR. GOTTLIEB Who does the screening?

DR. BELLAVIA First, they send in a resume. It should be typed and should look good. Your supervisor does the screening interviews and checks the references by phone-- people won't put anything negative in writing. Those who survive the screening fill out a questionnaire that gives you a pretty good idea of what kind of a person they are and their past history. It asks what they liked about their last job, what they think they'd like or not like about working here, what positions they think they'd like, and what positions they wouldn't like. It's like no employment application you've ever seen. One criterion is how far they live from the office. If they're more than a half-hour away, you're lucky if they last a year. If they are an hour away, they probably won't last three months. The health status of the applicant's children is also very important. More important than that is who is going to take care of them. If they don't have a concrete way of taking care of their children every

day, they are going to miss a lot of work.

All this brings brings it down to the few who are going to be considered for a second interview, this time with the doctor. If the doctor makes a selection, that person should meet the staff, possibly at lunch, to see how well they get along. You can go through one final step, especially with a chairside applicant-- that is to have them watch a whole day in the treatment area.

DR. GOTTLIEB Do you do any testing of the applicants?

DR. BELLAVIA After the questionnaire, we get a personality profile that tells us about four areas of their personality-- dominance, influence, steadiness, and compliance (DISC)-- and how they interrelate. I have done much research and arrived at a range of DISC weighting for every position in the practice. We also have ideal profiles for each position as a guide.

The second test is an alphabetizing test consisting of 50 cards with patients' names on them. If they arrange them all properly, fine. If they get five or ten wrong, you shouldn't let them near your files. There is also a mathematics test. If they don't do well on that, you don't want that person dealing with bookkeeping or statistics.

Then there is the manual dexterity test given to clinical staff; I use the DCA test. The manual dexterity test tells you about their potential. The wire bending part tells you how easy they will be to train. If they have potential and bend the wire well, they will probably learn quickly. If they have potential, but don't do well with wire bending, they may take longer to train, but will eventually do well.

DR. GOTTLIEB Do you use the Wunderlic test?

DR. BELLAVIA I don't feel it is appropriate. If a person has a fairly good education and experience, it's probably insulting for them to take it. It might be a good idea for people under 20 with little experience.

DR. GOTTLIEB Do you look for experienced or inexperienced applicants?

DR. BELLAVIA It's fifty-fifty. If you get an experienced person who is more concerned with the way you do things than with the way she used to do them, you're fine. But if her main concern is trying to prove to you that she knows what she is doing by telling you how it was done in her last practice, that's not good. The doctor has to establish that from the start. You want their opinions on changes, but not until they know exactly how it is done in your practice and why. You have to respect each employee for what they are, but let them know where they stand and where you stand.

DR. GOTTLIEB Do you believe in testing clerical skills?

DR. BELLAVIA Typists should have a certain number of words per minute. I would ask them and not test them. Unless they worked on the same machine, it is unfair. The best thing to do in that respect is to call their previous employer.

DR. GOTTLIEB How do you handle training the hiree?

DR. BELLAVIA We use a preplanned, scheduled program, in which they have to learn specific things each day over a period of weeks. There is a two- or three-day orientation on terms and

procedures, using a workbook and a textbook, and observing procedures. After the orientation, the clinical trainee does a week's worth of check-and-adjust training in which she learns to ligate and remove archwires. Then she learns how to form archwires by bending them on a typodont. She would start with one type of archwire and, after training, do just that archwire on patients for a day.The next day, she starts training on a new archwire. When that's all done, you take her into banding/bonding training. If you train properly, anyone with potential and a good trainer can be doing everything there is to do in the operatory, including taking records, in four to eight weeks. The more experienced the person, the faster she learns.

DR. GOTTLIEB How much information do you give them? Do you teach them why they are doing things as well as what?

DR. BELLAVIA They should be able to tell you why they are doing every procedure. I also believe that assistants should be able to do everything that the law allows. But there is a point in delegation where they start losing respect for the doctor if they do too much. The doctor should do the banding and bonding, the removal of bands and brackets, and all the intraoral activations.

DR. GOTTLIEB When do you reach a point where you need supervisors?

DR. BELLAVIA I would say you always need some kind of supervisory help, especially in large practices. To lessen the need for supervisory time, I suggest that the practice hire more mature people; between 22 and 40 are the best. They take more responsibility and they're more stable. In the smaller practice, 100 to 150 starts, the doctor is not going to worry that much about it, because he's usually in control of the staff. He only has a few staff members, and he knows what everybody's doing. If you have a two- or three-doctor practice with a staff of 15 or 20, you have a lot of people to account for, and you find that you can't rule them with an iron hand. You've got to use supervisors who are responsible, mature people.

DR. GOTTLIEB Do you believe in the position of office manager?

DR. BELLAVIA The one position I really don't feel works is the office manager. Unless you have an immense practice with 20 or more staff, I don't think this position could ever be justified. A lot of today's management approaches are not good because they create management positions for people who really don't have anything else to do. Creating an office manager position in a practice with a staff of 10 or less is absurd. She'll do nothing but antagonize everyone. The biggest problemI've found with practices that get into office manager thinking is imposed management. My philosophy is self-management. You hire the right people, organize them, schedule them, report on work done, and they manage themselves. You don't have to impose management on them.

DR. GOTTLIEB How do you decide on pay levels?

DR. BELLAVIA People should be paid what they are worth. If they are not, they won't be happy and they'll leave. They shouldn't be paid what they think they are worth. They should be paid what they are really worth.

DR. GOTTLIEB Do you favor annual bonuses in addition to salary?

DR. BELLAVIA I have tried everything, and I've come to the conclusion that there's only one type of bonus-- that is, whenever you feel like giving somebody something, say to them, "You've done a superb job. I just think you're great", and give them a few hundred dollars. But also say, "Now, this is between you and me. If it ever gets back to me that anybody else knows about this, this is the last bonus you'll ever get".

DR. GOTTLIEB Somebody writes the check, though.

DR. BELLAVIA Well, bookkeepers have to have a certain level of integrity, and bookkeepers do good jobs, too. They get bonuses, and they appreciate what is going on. I'm talking about quality people. Every other bonus system turns into a benefit system, and once it's a benefit system, they expect it. That's what's wrong with most so-called bonuses.

DR. GOTTLIEB How do you handle salary increases?

DR. BELLAVIA That's all automatic. Every position in the practice is worth as much as any other.If you hire a person at a certain salary and hire another person with more experience at a higher salary, with my system about two and a half years down the road they're both going to be at the same salary, except for staff with a lot of longevity and supervisors, who have to take on a certain level of accountability and responsibility in addition to their normal work.

DR. GOTTLIEB Do you believe in cost-of-living increases?

DR. BELLAVIA I have it set up as merit plus cost-of-living. After a three-month probationary review, you get a raise. Every six months thereafter for the next four raises, you get a merit increase because you are gaining knowledge and speed, and you are coming up to the level of the established people. Also included is a six-month, 4% cost-of-living increase. After those four periods, you only get a cost-of-living increase.

DR. GOTTLIEB Why every six months?

DR. BELLAVIA It's motivational. People just do not want to wait a year for you to tell them you like their work, which a raise serves to do. Every six months, the employee gets a raise, which is preprogrammed one to two years in advance, based on a six-month staff evaluation system. While the raise is automatic, the amount of the raise is not. The staff member is evaluated 50% on her personality and 50% on her position. She must be high in both to receive a full raise. Actually, a staff member may receive up to 20% higher than the scheduled raise if she is excellent. She may also receive only 70% or 80% of her raise if she is mediocre. The six-month salary review is also an excellent way of improving the staff member by scheduling training for her in all the areas in which she received a fair or poor rating.

DR. GOTTLIEB How is the evaluation done?

DR. BELLAVIA The doctor and the supervisor evaluate a person from their own point of view, discuss it, and arrive at a composite evaluation. Then the staff member is given a form to fill out on herself. The staff member and the supervisor then go over the staff member's self-evaluation. If the supervisor does not agree with it, they discuss why. The evaluation is done one or two months

before the actual raise, so that she has a chance to improve. The evaluation is repeated at the time the raise is due. With improvement, the staff member gets a better raise.

DR. GOTTLIEB I suppose that a lot of doctors don't do performance appraisals because they do not want to be finding fault.

DR. BELLAVIA But the problem is not who is at fault. The problem is to get them up to the level they have to be at, and make it work for everybody. Too many people approach problem solving with the idea that somebody's at fault. That's not problem solving, that's blaming.

DR. GOTTLIEB How do you time the hiring of additional chairside or clerical staff as the practice grows?

DR. BELLAVIA It's very simple. Every month my practices calculate their "12 magic numbers" that tell them whether their practice is under control or not. It's called a Control Report. From those 12 numbers I can tell everything that is right or wrong with that practice-- how the staff is performing, how the doctor's days are going, whether certain things in his communication are working or not, whether certain things in his reception area are going out of control.

DR. GOTTLIEB Does the Control Report include things like patients treated per day?

DR. BELLAVIA That's on the Staff Utilization Report. It tells you how many patients you see a day, and whether you need a full receptionist or a part-time receptionist, more staff or less staff, etc.

DR. GOTTLIEB But you don't wait until you are using your staff 130% before you add staff, do you?

DR. BELLAVIA Right. That's why we have the Staff Utilization Report. If you see 60 to 70 patients a day, you need a full-time receptionist. if your TC is spending 70% of her day in exams, conferences, and visit-related work, she is fully utilized, because her preparation and follow-up take another 30% of her time. The Communications Report tells me the number of exams and conferences and the percent of "will call backs" and "no treatment", which tells me how the TC is doing. That's where control comes in. In the average practice, 30% of the treatment conferences are "will call backs", because they are not sure they're going to go ahead. You may lose as much as 8% or 10% of your starts that way.

DR. GOTTLIEB How many patients are lost because of poor controls?

DR. BELLAVIA About 25-30% of the new patients who are referred.

DR. GOTTLIEB You are saying that only 70-75% of all initial exams eventually get started? What happens to the rest?

DR. BELLAVIA They are "will call backs" who never do or never get followed up on. If they are not followed up on, they just get lost or go someplace else.

DR. GOTTLIEB So the biggest potential for anybody's case starts is probably within his own practice.

DR. BELLAVIA Exactly. The gold mine is in your exams. If you can't convince the people coming in the door that yours is the place to be, you're doing something wrong.

DR. GOTTLIEB Actually, it should be relatively easy to improve the acceptance rate.

DR. BELLAVIA Yes, but with the economic conditions the way they've been in the last five to eight years, it's hard. I also have practices that are over 90%. When people walk in their door they just feel that they belong there. And these are the practices that have the biggest problem I've ever run into-- overstarting. They have no control on their starts. They don't realize what their maximumcapability is, and it takes two or three years to clean up the mess.

DR. GOTTLIEB Most of the orthodontists who answer our questionnaire say they could handle at least 50 more cases.

DR. BELLAVIA I find it is closer to 100% more cases. In other words, unless they are already in pretty high production, I find the average doctor is wasting 30-50% of his time.

DR. GOTTLIEB Doing things he shouldn't be doing, or just idle?

DR. BELLAVIA Losing a few minutes here and a few minutes there. I would rather have a doctor have a fully scheduled, highly productive day with four dental assistants going nonstop and getting everything accomplished than have a doctor working with two dental assistants with big ups and downs throughout the day. The doctor with four dental assistants produces twice as much treatment and actually feels less stressed at the end of the day.

DR. GOTTLIEB What do you consider to be an ideal appointment scheduling system?

DR. BELLAVIA Everything that has to do with an orthodontic practice is based on available doctor treatment time. The largest the practice can ever be, the smoothest the day can ever be, and the maximum income that can ever be attained are based on doctor treatment time. The best way to utilize his treatment time is with a sophisticated scheduling system tailored to his treatment philosophy and based on proper organization of his entire practice. There are 10 levels of scheduling sophistication. The higher the level and the better the organization of the practice, the easier it will be to achieve this goal.

DR. GOTTLIEB What are the criteria for going from level to level?

DR. BELLAVIA With Level 1 as the lowest, Levels 1 to 4 are those used by most practices. When you get to Level 5, you have a well-designed schedule in which you account for all of the assistants'time and most of the doctor's treatment time. But you do not usually have a smooth, productive schedule until you reach Level 6. Level 6 scheduling has about one Full Start and one-half to one Phase 1/Limited Start per day. Levels 7 and 8 are as sophisticated as Level 6, but the treatment mechanotherapy, efficiency of appointments, and delegation are greater. Level 7 and 8 scheduling have about one and a half Full Starts and one Phase 1/Limited Start per day. Levels 9 and 10 have very high levels of delegation and control, and are very efficient with the doctor's time. Level 9 and 10 production levels have two to two and a half Full Starts and one to one and a half Phase 1/Limited Starts per day per doctor. I usually use five-minute intervals of doctor treatment time at

Levels 6 to 8, and one-minute intervals of doctor treatment time at Levels 9 and 10.

DR. GOTTLIEB How about everybody else's time?

DR. BELLAVIA Everybody else's time is accounted for 100% also.

DR. GOTTLIEB And what's accomplished by having one-minute control, compared to five-minute control?

DR. BELLAVIA At Level 9 and 10 you're dealing with an extremely high level of production, which means an extremely high level of delegation. When you have an extremely high level of delegation, you can do many things on a one-to-three-minute basis.

DR. GOTTLIEB Do you favor doing like things at like times?

DR. BELLAVIA Basically, I like a clean mix every day. It is the only way to schedule productively. For one-unit appointments, I do like things at like times, but never on long appointments. If you schedule simultaneous banding/bonding appointments, you can't account for the doctor's time properly, and you'd better hope one assistant is much slower or faster than the others. Otherwise, the doctor will be needed in two or more chairs simultaneously. So one of my cardinal rules is you never have two long appointments of the same kind at the same time. I also encourage all staff to achieve the same level of quality and speed (plus or minus 15%), and work an average daily schedule.

DR. GOTTLIEB You still see the long appointments in the morning?

DR. BELLAVIA Oh, yes. It's hard to get around the school problem. Usually, 8 a.m. to 9 a.m. and 3 p.m. to 5 p.m. are reserved for shorter appointments. Long appointments are seen from 9 a.m. to 3 p.m., but you do have to have short ones from 9 to 3, too. Otherwise the doctor would be sitting on his hands. If you did nothing but bandings all morning with a fairly high level of delegation, the doctor would not be busy 40% of the time, which is a tremendous waste of time.

DR. GOTTLIEB Do you schedule more patients for faster assistants?

DR. BELLAVIA They get the same schedule every day, but they usually work a chair that has a lot of appointments in it, rather than a chair with a few very long appointments.

DR. GOTTLIEB Does an assistant stay with her chair?

DR. BELLAVIA Each assistant is assigned a chair for the day. Patients assigned to that chair are her patients, and she's got to get them in and out on time. That's her job. It's the doctor's job to make sure that he gets to her chair on time, so that she can get her patients out on time. That's why I account for every minute of the doctor's time in each chair. If DA #1 wants him for a debanding, he's not sitting over with DA #3 on an arch change. Now, of course, everybody gets a little behind here and there. You can never account for everything. Your schedule is going to work 85% of the time, and the other 15% of the time you just adjust to it. There's no way around it, because somepeople are going to come early or late or miss appointments.

DR. GOTTLIEB Doesn't it create staff problems if you have one person who is a lot faster than the others?

DR. BELLAVIA With proper screening and selection of staff, they are all usually about the same. If you get a very fast person in your practice, you should schedule her to work at one chair all the time, and to handle emergencies as they arrive so that everybody else can stay on time.

DR. GOTTLIEB Do the Levels 1 to 10 correspond in some way to the number of starts you have? You don't need to be at a Level 10 if you have 100 starts.

DR. BELLAVIA You probably cannot be at a 10 level if you only have 100 starts. But I have a start-per-day philosophy. If you work 200 days a year and start 400 patients, that's two starts per day (including Phase 1/Limited and Full cases), and you should be at Level 7 to 10.

DR. GOTTLIEB If you can start two cases a day, does that determine how many days a week you're open? Is it better to consolidate your appointments to the minimum number of days a week?

DR. BELLAVIA I think the minimum amount of time you can put into a practice is about two and a half to three days a week. But you can take long vacations. Some orthodontists work for three weeks and take the fourth week off.

DR. GOTTLIEB How much of a problem is minimizing days in a satellite office?

DR. BELLAVIA It depends on your definition of a satellite office. By my definition, a branch office is one that you rent or own, while a satellite office is a sublet of someone else's office. Normally, if you don't spend at least one day a week there, you're foolish to establish a branch office. Use a satellite. A satellite is a way of getting some patients you'd never get, and a way of picking up some more income by spending one or two days a month there; and it's a favor to those patients.

DR. GOTTLIEB It's a way of working yourself up to a branch office, too.

DR. BELLAVIA Exactly. But if it doesn't grow within one or two years, it isn't going to be branch office potential.

DR. GOTTLIEB What work is typically done in a satellite office?

DR. BELLAVIA In satellites you don't do heavy work. It's mainly for check-and-adjust, exam, and conference appointments. If your records are done in an outside lab, you can take impressions there, but full records are done in the main office along with all the initial bandings, debandings, and retainer insertions.

DR. GOTTLIEB How do you handle new patients who want all their appointments later in the day?

DR. BELLAVIA If patients know up front what to expect, they accept it. TCs, patient trainers, and the doctor must emphasize that "we're going to do the best we can for you and we want to take you out of school as little as possible; so we want to have 70% of your appointments before or after school and 30% during school". They accept it. If they don't, they have to find another practice.

There are other ways around that. You might work one night a week or one Saturday a month.

DR. GOTTLIEB Work nights, you say?

DR. BELLAVIA Yes, you might work from 12 to 8 instead of from 8 to 5 one night a week. That'stypically good for big practices, but usually not in smaller practices. You can't get many people to come in at night, normally, unless you have a high percentage of adults or working mothers in your practice. I haven't seen it work out too well except for large practices.

DR. GOTTLIEB Unless the doctor does case presentations himself and wants to do them at the convenience of the parents at night.

DR. BELLAVIA You have to determine the quality of life. A doctor may see patients from 8 in the morning to 5 in the evening, and then stay until 6:00 or 7:00, seeing exams and conferences. His quality of life is not nearly as good as it should be, because he's not seeing his family very much, and his wife and kids don't get much time with him; or if the kids are very young they may even be in bed by the time he gets home. So it's a quality-of-life decision. He might say, "Well, I may lose 5% of my patients, but I'll lead a happier life". In most cases I find they don't lose any patients. Once they start the TC program, they may lose 5% because of that, but they usually gain 15 or 20% because they have better communications.

DR. GOTTLIEB When do you schedule the treatment conference or new patient exams?

DR. BELLAVIA People love the 4:15 or 4:30 appointment or a 9:00 a.m. conference or exam. Exams and conferences are also scheduled in the late morning and right after lunch. Patients are not as happy with those in the later morning, but they take them.

DR. GOTTLIEB Do you feel that the case presentation should be a one-visit, two-visit, or three-visit procedure?

DR. BELLAVIA I don't feel that you should rush somebody into a four-year commitment. I think they have to be brought in more slowly. I do think it's a good idea to have an exam with records so you can save them one visit, especially if they live far away.

DR. GOTTLIEB How does that work out with a precise scheduling system?

DR. BELLAVIA It's always built in. You always have an exam followed by a full records appointment, whether you use it that way or not. Most practices use it 50% of the time.

DR. GOTTLIEB Do you have a fee or fee range quoted at the first visit?

DR. BELLAVIA Yes. I find that you can avoid a great many problems and a lot of extra work by doing that. You can't quote every fee. You can't always quote a fee for surgical cases or for someborderline extraction cases. But that's only about 10% of the practice. You can quote a fee for the other 90%.

DR. GOTTLIEB Do you think you lose as many people by not quoting a fee as by quoting a fee before they understand the value of the service?

DR. BELLAVIA Well, if you give a good exam you do show the value of the service very well. The kind of comprehensive exam and explanation I use cover the problem and reassure them that it is going to be resolved. That's what they want to know. Most of them are going to be treated; you've just got to convince them that yours is the best place. When we started giving the fee at the exam, the number of treatment conferences that got started went up 5%. Some people were shoppers who just wanted to hear the fee anyway; but we didn't have to waste a diagnosis, treatment planning, and case presentation appointment on them.

DR. GOTTLIEB That would imply, though, that the father doesn't need any convincing.

DR. BELLAVIA There are fathers who have an interest and a concern, and there are fathers who say, "Whatever you want to do is great and I'll support you, but I don't want to lose time fromwork". If the father shows up 20% of the time that's a lot. I find that if the father wants to come, that's great; but if he doesn't want to come and he's there, that's the worst thing that could happen. He may be annoyed, or he may be losing income because he's not at work. Fathers do show up a lot more if you have evening conferences.

DR. GOTTLIEB Of course, now you're dealing with working women. They're in the same boat as far as their time is concerned as the father has been.

DR. BELLAVIA And those are the ones who always want the prime appointments later in the day or early in the morning, which is fine. They have to wait a little bit longer down the road to get started, because those are the appointments that fill up first.

DR. GOTTLIEB Does it change your approach to anything that you have working mothers, and kids arriving at home without a parent at home and with less supervision, not only to get to their appointments, but to do what they're supposed to do?

DR. BELLAVIA I think that the number of missed appointments is much higher because of that.

DR. GOTTLIEB Is this widespread enough now to be thought about as a separate management problem? You could see them more often, for instance.

DR. BELLAVIA The more often you see them, the more you're going to clog up your schedule and the less chance you have to get them in if they do miss an appointment.

DR. GOTTLIEB Do you advocate a system of rewards as patient motivation?

DR. BELLAVIA Oh, there are all kinds of gimmicks, but there is only one thing that really works-- make the patient an important person. If every doctor and staff treated every child patient as they do the adult patients, they probably would have fewer problems. It is natural for patients to feel important, and thus they should not be ignored or handled as though they were on an assembly line. You can have a highly productive practice and still make each patient feel important.

DR. GOTTLIEB Are you scheduling adults into the open operatory with child patients?

DR. BELLAVIA Most of them want to be there. At least 80% enjoy being in the open operatory. There seems to be a little bit of flack about sitting on deck, and 20% feel uncomfortable in the open

operatory, but you can have a semi-private operatory in the open bay and have the best of all possible worlds.

DR. GOTTLIEB Do you believe in an adult fee?

DR. BELLAVIA I think adult fees are typically higher than child fees. A chitchat factor is usually the most important reason. Some doctors feel that the amount of treatment time is increased and charge extra for that. Some think that adults are harder to strap up because they can't handle pain, and thus require 30% more start-up time than usual.

DR. GOTTLIEB How much of a problem is the chitchat factor?

DR. BELLAVIA It is important, but I find that the problem is usually caused by the doctor and staff. Doctors force themselves to spend more time with an adult than they would with a child because they think they're supposed to. The one fact that must always be remembered is that all patients have to feel important. Their self-worth is number one to them and getting treatment done is number two. If you can keep that in mind, you can give a good service and motivate all patients. Of course, unless you are properly scheduled, you won't have time to do that.

DR. GOTTLIEB Does social class make a difference?

DR. BELLAVIA Well, it depends on the area. It's interesting that the very rich and the blue-collar are very much concerned with the treatment; and they usually cooperate fairly well. In the high middle income area, the parents are so busy trying to make it that they don't spend that much time with their kids. The mother and father are working, and the child doesn't get much quality time with them. They tend not to cooperate and to give you a hard time.

DR. GOTTLIEB If you have a TC, she'll have more to do with identifying that type of person than the doctor will.

DR. BELLAVIA That's why she spends most of her time working with the patient at the exam. When she goes out and tells the doctor what's going on, she's pretty sure of the patient's general attitude. It's amazing. You can just ask two questions that will tell you 60% of what you want to know. The first question is, "Who first noticed the need for treatment?" If it's the child, you have somebody who is interested in treatment. The second question is, "How do you feel about orthodontic treatment?" You can learn more about the child than you can imagine, but very few offices ever get the child involved early and ask that question.

DR. GOTTLIEB If he says he doesn't want treatment, do you believe him?

DR. BELLAVIA It depends on how he says it. Some of them say it because they think they're supposed to say "no". But if they sit there with their arms crossed, that's something else.

DR. GOTTLIEB Do you recommend that patients participate in the decision making about what'swrong and what's going to be done?

DR. BELLAVIA Most orthodontists have alternative treatment plans. There may be possibilities of full or limited treatment, especially with adults.

DR. GOTTLIEB In orthodontics, though, you really can't compromise too much, or what you wind up with wasn't worth starting in the first place.

DR. BELLAVIA That's exactly my concept of practice optimization: you can't do partial treatment and produce an ideal result.

DR. GOTTLIEB In a sense, I think that we come into conflict with the modern idea that people are concerned with their own health care and should have a part in the treatment decision, and that we are too rigid in going only for home runs or trying to turn out only Cadillacs. But the question is really whether you're doing somebody a service by compromising your treatment goals.

DR. BELLAVIA It's rare for me to see more than 10-15% of adults going with an alternate treatment plan, other than for surgery versus full treatment. I don't see too much limited adult treatment, unless it's for something minor. If they don't need full treatment that's something else. So it does seem to me that most patients need and want home runs. You have to consider the ego and integrity of the orthodontist. If a person cannot live with a bunch of semi-treated cases running around with his name on them, then he can't, and that's all there is to it. He will never compromise.

DR. GOTTLIEB How does your schedule handle emergencies? Do you have an emergency chair?

DR. BELLAVIA That's built into the schedule, and you can use a cancelled appointment as an automatic emergency slot.

DR. GOTTLIEB Do you have a percentage for emergencies?

DR. BELLAVIA I do it on hours. I find hours are more accurate, because most offices don't count the emergencies that happen in the chair. A child comes in for an upper and lower arch, and he's got three bands off. Instead of a half-hour visit, now it's an hour-and-15-minute visit. Most people don't count that, but I do. If they only counted the people they scheduled for emergencies, they'd have to double it to find the real emergency time. Two to two and a half hours a day is typical for a well-control led, 300-start practice, and one and a half hours a day for a 150-start practice. Awell-controlled practice has a patient orientation and chairside training program, and the TC and receptionist also encourage the patients to do what they have to do, trying to avoid emergencies.

DR. GOTTLIEB I've looked at appointment books that have E's all over the place. Their emergencies are not under control.

DR. BELLAVIA There are two reasons for that. One is that they are not training the patients properly, and two is that they may not be training their staff properly. The staff may not be banding or bonding properly. If you bond lower 5s, you can figure 40-50% will be knocked off. That's why my idea of an ideal strapup is to band upper and lower 6s and lower 5s, and as many 7s as you want; and to bond upper 5-to-5s and lower 4-to-4s. I think that's the least problem-oriented and most productive way. if you bond the lower 5s and then have to band them later, you lose both on treatment time and appointment time, so what's the gain?

DR. GOTTLIEB How do you handle broken and cancelled appointments?

DR. BELLAVIA With a cancellation control list. You keep a list of all the cancelled appointments

so that you can put other people in there.

DR. GOTTLIEB Do you believe in overbooking?

DR. BELLAVIA You can. Let's say you're going on a trip for a week. You cram appointments in the week before and the week after. That's fine as long as you don't do it too often. There isn't any staff member who couldn't work at 150% of her capacity for a short period of time.

DR. GOTTLIEB Some patients are going to be shortchanged. Treatment times get longer and the whole practice suffers.

DR. BELLAVIA Definitely. If you are trying to do 50% more work than your normal schedule calls for, there's no way that the patients are going to get your best service. You are trying to work at a production level that is way above what you're capable of. Too often you're overscheduled. You can't give the patients the quality time they need to get them done on time, so they run over a little bit, and treatment time stretches out to two and a half or three years.

DR. GOTTLIEB Do you figure on a "normal" number of broken and cancelled appointments in a day?

DR. BELLAVIA I find that it's between 10-15% of the number of patients a day or the number of hours of total treatment time.

DR. GOTTLIEB I like 5% of the appointments, but I may be low for the average practice. What do you do about the no-shows?

DR. BELLAVIA Well, it's kind of funny. The smaller the practice, the looser the schedule, and the more you can give people what they want, the more no-shows and cancellations there are. I have yet to see a very busy, high-production practice get cancelled very much. It may be 20% in a small practice, but it may be 10% in a busy practice, because those patients know they're going to have to wait a long time for another appointment, since the practice is solidly booked every day.

DR. GOTTLIEB Do you have a method for setting fees for various types of cases?

DR. BELLAVIA It takes 28% of the work to get patients fully into treatment-- exam, records, diagnosis and treatment planning, case presentation, orientation, and initial appliances. It takes another 12% for every six months of treatment, and 24% to get them out-- debanding, retention appliance, records, conference, and retention checks. Thus, if a 24-month case fee is $2,500, it takes $700 to get them in and fully strapped up, $300 for each six months of treatment, and $600 to get them out. An 18-month case would be $2,200, a 15-month case would be $2,050, and a 12-month case would be $1,900. Many orthodontists undercharge for these cases. They figure a 12-month case is half a 24-month case, and charge about $1,250 instead of $1,900. Those who do a lot of Phase 1 treatment can easily find $10,000 to $50,000 a year in "misfeeing". The philosophy of cheap Phase 1 and expensive Phase 2 will also kill you financially. You may never get to Phase 2. Palatal expansion is a major treatment. The fee should be $600 on the basis of a $2,500 24-month fee, but few will charge $600 for eight weeks of treatment.

DR. GOTTLIEB Do you believe in breaking down the fee for the patient?

DR. BELLAVIA No. The biggest problem an orthodontist has is in selling hardware instead of service.

DR. GOTTLIEB Your method of fee determination should work well on transfer cases.

DR. BELLAVIA Yes. For example, if a transfer-in case has six months' worth of treatment left, that's 12% for six months of treatment plus 24% for getting out and through retention-- that's 36%, and 36% of $2,500 is $900. Few doctors charge $900 for a six-month transfer-in case.

DR. GOTTLIEB But if you are not busy enough . . .

DR. BELLAVIA Then you take them in at whatever you can, because $500 or $600 is better than doing nothing. On transfer-in cases, the fee for the remaining treatment should be 24% of the full fee plus 2% a month for the remaining active treatment. If eight months of treatment remain, the patient should have paid the first orthodontist only 60% of his fee, and the second orthodontist 40% of his fee. I believe in a minimum of 12 months of retention, and two years is even better. The total fee would include two years of retention, and anything after that is on a per-visit basis plus appliances.

DR. GOTTLIEB What do you think of separate retention fees?

DR. BELLAVIA That's bad. I have seen many patients lost and much ill will created with a separate retention fee.

DR. GOTTLIEB It also gives the patient the option of not going through with retention. If retention is important, it should be included in the treatment fee.

DR. BELLAVIA The reasoning was to make the up-front fee look smaller, but it just didn't work. I think those who do it will find that many of their past due accounts are retention fees that have not been paid. Patients should feel good at the start of retention, and retention fees negate that feeling. There is no doubt that the retention conference not only aids success in retention, but it also promotes patient referrals.

DR. GOTTLIEB Do you see orthodontists in jeopardy from franchises?

DR. BELLAVIA Established orthodontists who work for franchise dentists can ruin themselves. When their referring dentists hear about it, they cut them out. But most of those working for franchises are not established orthodontists. I haven't seen any decline in a good orthodontic practice as a result of low fee competition. Three classes of people are receiving orthodontics-- the under-$1,300 full case, the $1,300-to-$2,000 full case, and the over-$2,000 full case. The over-$2,000-case people never consider paying anything less than that, and they are your patients. The under-$1,300 people would never be your patients anyway. They would never dream of paying more than $1,300. The only way they may come in is with insurance. So you never had the under-$1,300 market, and you can't lose what you never had. The $1,300-to-$2,000-case people are the ones you have to market, and the only way you will do that is with a good service.

DR. GOTTLIEB Do you have any feeling about asking lay people directly for referrals?

DR. BELLAVIA At the time of the retention conference, at the beginning of retention, I think it is important to show them the before models and photographs, and have the patient there as the after model. Explain what you have accomplished, what the problems have been, and how they may affect retention. Finish off on a very positive note, and say that you hope they really appreciated it, and if they have any friends who would like to be as happy as they are, you'd be more than happy to see them and give them as nice a service.

DR. GOTTLIEB Does the TC do this?

DR. BELLAVIA Or the doctor if he is a good communicator. Many orthodontists miss out on the front end at the initial exam, where they should say, "We really appreciate your choosing our practice for your evaluation. Thank you, and I will be looking forward to seeing you in a few weeks". Just something simple like that will work wonders. Then, after the case presentation, thank them for deciding to have treatment in your practice. It makes people feel good about your practice. Along the same line, remember their name and something about them, and make them feel important every time they come in. How well you do this will determine the success of their treatment and the likelihood of future referrals. People are usually most enthusiastic about the practice in the first three months. So do a good job up front.

DR. GOTTLIEB And ongoing communication is so important.

DR. BELLAVIA Yes, you really should let them know what's going on and where they stand. Achief complaint by patients is that they do not get enough communication. I am against the visit-by-visit evaluation. It becomes unimportant if it is done all the time, but a six-month progress review is significant.

DR. GOTTLIEB What kind of confirmation letter do you advise?

DR. BELLAVIA It's important to follow up your case presentation with a letter welcoming them to the practice, explaining what kind of treatment will be done and how long it will take, and outlining some of the office procedures such as out-of-school appointments.

DR. GOTTLIEB Do you include the financial arrangements?

DR. BELLAVIA No. I don't think you should mix the finances and the treatment. Besides, they have a financial arrangement form that they have agreed to, and discussing finances is both superfluous and insulting in this letter. It makes you look money-hungry.

DR. GOTTLIEB Do you advise short form letters to GPs?

DR. BELLAVIA I have only seen two dentists who didn't prefer them over typed letters.

DR. GOTTLIEB Behaviorists say that people don't like form letters.

DR. BELLAVIA Ours is a different kind of form letter. It's half check-off and half personalized, written by the doctor. And it's ready for mailing right after the exam or case presentation.

DR. GOTTLIEB Do you advocate asking dentists how they want to be communicated with?

DR. BELLAVIA Yes. We have a referral preference form. The dentist tells the orthodontist what treatment he wants to do, and, if not, to what specialist he wants it referred. You don't bug himevery time you need to refer the patient to a specialist, and you don't refer work to a specialist that he wants to do himself.

DR. GOTTLIEB What do you do to encourage dentist referrals?

DR. BELLAVIA The classical methods. Knowing him personally, liking him personally. Your families knowing each other. Your staff knowing his staff. One nice thing is to have a two-hour lunch once a month or once every two months and invite a different dentist and his staff. The girls in your practice make the lunch themselves. You give the visitors a tour of the office and someunderstanding of an orthodontic practice. The receptionists should know each other very well. And, of course, one of the best things you can do is have the dentist's staff sitting there with a mouthful of your hardware. Their patients will want to know to whom they go for orthodontics.

DR. GOTTLIEB How much of a fee reduction do you offer them?

DR. BELLAVIA I would offer 25% as long as they work for that dentist. I think 50% is too much.

DR. GOTTLIEB Do you use patient feedback surveys?

DR. BELLAVIA Yes. On the six-month treatment progress review, you evaluate them, and they have a right to review you. I simply ask them how they liked the service and how it can be improved.

DR. GOTTLIEB Do you have them sign the questionnaire?

DR. BELLAVIA Never, although most sign it anyway. It's understood that the answers are confidential. If you send out 300, 100 will respond. Of that 100, 90 will give you glowing grades. Of the other 10, 7 will suggest improvements and 3 feel they have been wronged. You generally know who they are.

DR. GOTTLIEB What suggestions do you have for the doctor who doesn't relate well to patients?

DR. BELLAVIA He must surround himself with a staff that can. The practice must realize that it has to make the patients feel important. Everything gets back to that. If there is one thing you can do that will make them cooperate and refer patients to you, it is just to make them feel important. If the doctor cannot do this, his staff must do it.

DR. GOTTLIEB Is a doctor who does not relate well to patients likely to relate well to staff?

DR. BELLAVIA Probably not. If the orthodontist is insecure and a nitpicker, and doesn't give his staff some breathing room, the practice tends to be tense, and that isn't a positive, happy atmosphere for staff or patients.

DR. GOTTLIEB Do you have any feeling about the so-called generation gap in dentist referrals?

DR. BELLAVIA Partly it's a fact of life, and partly orthodontists let it happen.

DR. GOTTLIEB Can that be corrected by taking on a young associate?

DR. BELLAVIA I don't have many clients in their 50s and 60s who don't have partners. If you are over 45 or 50 and taking in a partner, it is better to take one right out of school. If you are in your 30s, you should get somebody on your own age level. If you have only been in practice four or five years, you are not prepared to take in a younger person. You are better off with somebody your own age, making sure that between the two of you, you encompass the whole range of treatment. If you do nothing but fixed treatment, you are losing the functional market. If you only treat children, you are losing the adult market. If you do adults, you'd better do TMJ and surgical orthodontics.

DR. GOTTLIEB What is the best arrangement with an associate?

DR. BELLAVIA You can have a per diem associate, who comes in occasionally to cover the office, and you can have a contracted per diem, who comes in every week on certain days. There is a buy-out associate, who is buying in as you are phasing out. Then you have your full partner.There can be a sharing partner-- you both have your own practices in the same office, and share certain staff and common space. You have your own operatories and clinical staff, and your own incomes.

DR. GOTTLIEB When should you consider a partner?

DR. BELLAVIA If you are overworked or want more time off, you go into a per diemarrangement. If you want a permanent reduction in your days, you go to the contracted per diemassociate. If you want to divide the ownership and the responsibilities, you want a full partner. If you want to phase out or sell out, you find a buy-out associate. When choosing a partner you are really interested in a good personality match. If one is high dominance, the other had better be high influence. Two high dominants won't work at all.

DR. GOTTLIEB Does it help to travel in different circles?

DR. BELLAVIA Yes, and belong to different clubs, but the treatment philosophy must be the same. There has to be staff acceptance of an associate. If he's a partner, the staff has to get along with him, or you get rid of the staff. One consideration is that an associate may be a threat to you, if he is located in his own office too close to yours and he is a go-getter. If so, he may try to steal your patients. If you have someone who is not going to be a partner, be sure that you do all the preactive recalls, exams, conferences, and maybe even initial appliances. All he should do is ongoing treatment. You never want him involved with the marketing end.

DR. GOTTLIEB What beginning arrangements do you advise?

DR. BELLAVIA In phasing the associate in, he should be on per diem for one year probation. Adecision is made at that time, and arrangements may be made for a buy-in. A salary differential is the best way to buy in.

DR. GOTTLIEB The advantages will usually be with the person buying in, because he's buying in with the practice's own money.

DR. BELLAVIA There should be a down payment, but there usually is not. The average partner

gets paid about $150-600 per day. The average is about $250 per day. It depends on a lot of factors, including what part of the country you are in.

DR. GOTTLIEB Can covenants not to compete really be enforced?

DR. BELLAVIA No. The Supreme Court said you cannot deny a person the right to work.

DR. GOTTLIEB So you have a potential problem any time you bring someone into your practice.

DR. BELLAVIA That's a point. That's why you want to bring in someone who has a practice 30-50 miles away who isn't a threat, and then if he ends up being a partner, you have a branch office one or two days a week when you merge practices. You can always phase out or sell the other practice if it is growing.

DR. GOTTLIEB I believe we ought to talk about computers, because to my mind computers are going to become a major tool in orthodontic practice.

DR. BELLAVIA A computer is just another piece of equipment, but it is a sophisticated one that requires a lot of care in handling. The biggest mistake a practice makes is not to have someone 100% responsible to see that everything is done properly. Computers are touchy machines. Things can go wrong with software and hardware.

DR. GOTTLIEB What are the minimum things that an orthodontist should want to get from a computer to make it worthwhile?

DR. BELLAVIA Accounts receivable, past due control, basic patient history, and reporting. Equipment must be expandable upward, and software should fulfill all your needs from the start.

DR. GOTTLIEB Before you have used up the effective life of the computer you want to do more with it.

DR. BELLAVIA Right. I set up my computer system in two packages-- one with scheduling and one without scheduling. The basic system, without scheduling, encompasses every conceivable thing you would want to use a computer for in orthodontic practice-- things that most orthodontists wouldn't even conceive of like calculating staff salary profiles, calculating fee schedules, and doing sophisticated reporting. This allows for all kinds of controls that tell you what patients to follow up on, "will call backs" for exams and conferences, lists of patients, letters to be sent, printouts of letters, past due control, etc.

DR. GOTTLIEB How much of the computer-generated information does the orthodontist deal with?

DR. BELLAVIA In my system, all the orthodontist has to do is get his control reports every month-- 12 numbers-- and the computer will tell him what's wrong with his practice.

DR. GOTTLIEB I guess orthodontists have two fears. One is the fear of putting data into the box and not being able to get it out, and the other is the fear of making a large investment in a systemthat may not be forever.

DR. BELLAVIA I use Data General hardware because it is upgradeable, and maintenance and repair are excellent. It is the only small computer company I know of with its own service force in every area of the country. You know that they will be there in a couple of hours for maintenance.

DR. GOTTLIEB It is confusing for orthodontists to understand what's being offered to them and whether that's really what they need for the next five years.

DR. BELLAVIA One of the problems of software is that it must work manually before it will ever work on a computer. The practice is not really concerned with how the computer processes things, as long as the printout from the computer resembles the manual forms they are used to. My systemis based on manual systems that have worked well in hundreds of offices for the past decade.

DR. GOTTLIEB Many knowledgeable people say you don't put scheduling or treatment cards on the computer because, if the computer is ever down, you are dead in the water.

DR. BELLAVIA I was against computerized scheduling at first, because I felt that if the computer went down at 3:00 in the afternoon with 50 patients scheduled, you would be in trouble. I had so much pressure from orthodontists to put it in that I came up with a concept of failsafe scheduling. It includes a printout of every available appointment and of every appointment given. If the computer is down, you can continue scheduling manually.

DR. GOTTLIEB What about treatment records?

DR. BELLAVIA The second thing I felt never belonged on the computer was treatment records, because it took so many terminals and so much time to enter the information. In my system, you automatically generate the treatment chart every time you give an appointment. As the appointment is completed, you specify exactly what you did, which takes about 10 seconds; then you tell the computer what kind of an appointment you want and in how much time. All this is done by the receptionist. I don't like screens at the chair and appointments at the chair. Treatment staff are there to treat patients, not to play with computers.

DR. GOTTLIEB If the computer goes down, how do you handle the treatment information?

DR. BELLAVIA We have a manual Tx chart used at the chair.

DR. GOTTLIEB Who should not have a computer?

DR. BELLAVIA I don't see any practice under 200 starts needing a computer. If they just like computers, that's different. For some practices, it is a marketing technique. They have all those computer controls, and patients are impressed and appreciate it because they see a nice service coming from those controls. Anybody who is not prepared to control their computer system, using the proper staff, shouldn't get one. The idea behind controlling your practice is to see what is wrong with it and resolve it. The reports tell you that you are getting things under control, or that they are going out of control, along with sufficient data to give you the means of resolving any problems.

DR. GOTTLIEB Does a computer replace personnel?

DR. BELLAVIA It depends on the size of the practice. The accounts receivable posting takes half

the time on a computer, and billing takes a quarter of the time. The financial system itself and computerized insurance billing and past due billing all save time.

DR. GOTTLIEB Can you figure that anything you buy today is probably obsolete, because the technology is ahead of the market?

DR. BELLAVIA That's why you have to buy a system that is upwardly mobile, that can be expanded in both hardware and software to meet the needs and desires of the user. In general, when dealing with computers, follow the ten commandments of computers:

1. Get your practice organized, and select the proper kind of person to operate your computer.

2. Control the manner in which the data gets to the computer operator to be entered.

3. Don't buy a system if its entire design was based on just one orthodontist's practice, with just his philosophies. You are buying his problems.

4. Don't buy a system unless it was designed specifically for orthodontists.

5. Make sure it is installed quickly and correctly, with as little of your staff's work as possible to get on line.

6. Make sure that you can get software maintenance over the phone line any time you need it.

7. Make sure that your software people have a good track record and will be around for a long time.

8. Make sure that your hardware system is upwardly mobile for expansion.

9. Make sure that you can get competent hardware maintenance immediately.

10. Make sure your hardware company will be around for a long time.

DR. GOTTLIEB Many thanks for a fascinating look at a real practice management system.