It's About Time
Here is an interesting group of data: JCO Orthodontic Practice Studies have consistently reported that the standard for length of full orthodontic treatment is 24 months, and that the average practice experiences two emergency appointments, three broken appointments, and two cancelled appointments per day. Since it usually takes time to reappoint patients, these missed appointments and emergencies must account for some of the 24-month average treatment period. In fact, in many cases it takes a full appointment interval--four to six weeks--to reappoint. Just one missed visit moved back six weeks will stretch an 18-month treatment into a 19½-month treatment.
Assuming a high level of operator skill in the average orthodontic practice, other sources of lost time include poor patient cooperation, poor patient communication (as in not reporting lost or broken appliances), and patient vacations. One might speculate that the time it takes for ordinary full treatment could vary from less than 24 months for patients who have less-than-average lost time, to 24 months for patients who have an average amount of lost time, to more than 24 months for patients who have greater-than-average lost time.
The frequently expressed belief that cases are really treated in 18 months may result not only from a failure to monitor the actual time, but also from considering cases in which everything went according to plan with a minimum amount of lost time. When a full-treatment case in our practice treats out in 14 to 18 months, we ought to take the patient's lost-time record into account. We might find that the speedy treatment did not result from technical brilliance or some physiological phenomenon, but from optimum scheduling. It would be an error to buy into the idea that because it is possible to treat a case in 18 months, fees should be set on the basis of that standard. Not when cases are reported to take an average of 24 months to treat.
A better approach might be to simply assume that patients average 24 months of treatment time. This will turn out to be correct most of the time. Each orthodontist then has the option of rewarding earlier finishes or presuming that an early finish is a reward in itself. The first broken or cancelled appointment can be the occasion for discussing lost time and its consequences with parents and patients. At that point, or even before treatment, a limit on the acceptable amount of lost time can be set, and an understanding can be reached that charges may have to be made for time lost beyond that amount.
Regardless of how one chooses to set fees and present them, reducing lost time can be a real asset to the practice. It is not entirely a matter of luck in having unusually cooperative patients, although that is a contributing factor. In fact, most offices contribute to their own lost-time problem by failing to make time available in each day's or each week's schedule to speed up reappointments and the prompt and complete handling of emergencies. The "open day" has been offered as one solution. Orthodontists who accept lost time as inevitable and fail to plan for it, as with an open day, accept co-ownership of the problem, which can lead to a continuation of treatment past 24 months at no additional charge or to a confrontation with parents about the extension of monthly fees. Transfer cases frequently illuminate the problem and create significant ill will for the specialty when treatment lags behind payment.
Staying on schedule in treatment requires a scrupulous monitoring of lost time for every patient and a program to thwart all the thieves of time. Some offices elicit better cooperation than others through appointment policies that attempt to accommodate all patients' schedules, through studied avoidance of emergencies, and through communication procedures that optimize rapport with patients. Telephone reminders have been shown to be effective in reducing missed appointments.1 For offices that have not paid attention to the numbers that add to the length of treatment, much will be gained by shortening treatment times and improving patient relations--and it's about time.