How to Make an In-house Specialist Successful

This has been a hot topic in recent years. As a background, I have had endo, surgery, and perio in my office for about 9 years now, with a variety of different providers. I firmly believe this type of model is only going to grow in the future. It is an amazing way to provide great value to both the doctors and the patients. 

The basic idea is having a Provider come to the office to do procedures that the Host does not do. I am going to refer to the traveler as a Provider, because it can be either a specialist or a general practitioner that focuses on specific procedures. So why would either party do this non-traditional arrangement?

For the host, it helps bring in additional income to the practice with minimal additional cost, which helps stem the tide of lower reimbursement and growing corporate and competition concerns. It also brings more convenience and value to the patients, who are going to often comment on how great this is for them; this can help greatly with patient retention over time. Our current society is all about convenience of one stop shop models; just look at Super Target, Walmart, Amazon, etc.

I can also tell you from experience that the patients end up getting the treatment they need far more often. When we brought services in the office, we noticed a 4x increase in patients getting their treatment completed vs referring them out.

For the Provider, this becomes the ultimate lifestyle business that gives you unlimited freedom. First, the cost to building an office build in today’s world is often $500,000 and up. With a traveling business all you need are mobile equipment and supplies, often bringing you well under 20% of the start-up cost. You also remove the traditional fixed overhead costs of maintaining an office: rent, utilities, and maintaining the building and built-in equipment. About the only costs you will ever have with this model is your variable costs of supplies and assistant. What this translates into is a business where you do not lose money when you are not working. This is what is called a lifestyle business because you can plan your business around your life, instead of your life around your business. Want to take a vacation or break? Great, do it without the usual stress of needing to pay for the home office you are leaving behind.

Due to this being a non-traditional approach many concerns often arise from dentists. Most concerns about this practice model come from misinformation or lack of knowledge, because there are solutions to almost everything. You just need to think outside the box since the concept is non-traditional. Here are the most common concerns and ways to solve them:

Fees – If fees are not high enough it can cause a lot of issues on both sides (Provider and Host)

Solution – The Provider should be out of network. This gives you far more control and better ability to treatment plan quickly and easily. I run a mostly PPO office and this is rarely a problem, the few times it is there are simple ways around it.

Scheduling – Can be specific days or week/month, or flexible As-Needed for patients. Depending on the specialty, one or the other option could be better.

As-Needed allows the host to have more flexibility to schedule patients, the provider has less concern about a specific office needing X amount of work to come in. It is also far easier for the provider to build up an office base like this. However, As-Needed takes more organization on the part of the Provider to manage locations and does require more locations in general to run efficiently.

Specific days takes longer to build because the Host has less ability to schedule around patient needs, and therefore is harder to get Host offices onboard. It is easier for the Provider to organize.

Either set up though requires good communication. The Provider should give the Host team a full fee schedule that also includes how long to schedule for each procedure.

Home Offices – A home office makes this arrangement far less worthwhile for both Host and Provider. For one, the Provider loses the overhead gain that you can get from travelling, which as mentioned at the beginning is one of the biggest reasons this model is a win for the Provider. Second, the home office is always the baby that gets the most attention, which means the Host will play second fiddle (and they will often feel it). 

Solution – The most successful way to travel is to do it as your full-time model because as a business model you end up with almost zero fixed overhead. Your only costs are when you are working, which gives you amazing flexibility and profitability.

Skill of the Provider – absolutely this an issue. However, this is an issue with every dentist owner, associate, or referral in the world. Which makes this no different comparatively with any other type of setup.

Enough Patients – This is a problem if the specialist only has a handful of offices, and/or if they try to book specific days of week/month. This is another reason the most successful setup for travelling is not having a home office. When you are starting up you have no fixed costs to worry about needing to cover financially until your income takes off. Once you have a stable base of offices this problem no longer matters.

Post-op Care – Who does them if the specialist is not there every day?

Solution – If they come on a regular basis, the Provider can do these, but it does take time. However, most post op patients are not that difficult and with a little training and knowledge the Host should easily be able to manage a vast majority of these. For the few patients that they cannot, the Provider can easily see the outlier cases at a nearby office they are at that day. All it takes is a little communication with the traveling provider.

Scare/Fear Tactics:

When looking into this concept there is a subset of specialists who will try to scare anyone away from this model. There is really no reason for them to feel threatened by this model. To the specialists this is no different than another specialist setting up an office near them. A new provider is going to end up taking just as many patients away from you whether they have a fixed location or a mobile one. So, let’s shine some light onto these scare tactics to clear up the misinformation:

Fee Splitting? This arrangement is NOT fee splitting in any sense of the term. The payment arrangement is not much different, if at all, then having a normal associate. You pay them by a percentage of their production/collections just like any other dentist associate in an office. The only way to consider a traveling arrangement fee splitting would be to call every associate dentist in the country illegal as well. Fee splitting is very specific: a referral provider paying the referring provider a split of the fee they get from a patient. In a traveling model, the host dentist is the one paying the provider, exactly like any other associate.

Emergencies – There is a concern that the safety of traveling providers can be an issue, less for the provider and more for the host facility. First, the Provider needs to be solid on their emergency prep and to have all their emergency gear with them. This is no different than having your own fixed facility. The nice part is all emergency equipment now comes in mobile variety, you just need to make sure you bring it inside with you for easy access. For the Host facility there are a few things to manage, but they are quick and inexpensive to add on if the Host does not already have them in place. Last is training. The Provider is likely to have trained people just like they would in a home office, but the Hosts may not. This just brings another opportunity to the Provider to bring value to the Host. Train the Host teams yourself and solidify your relationship as well as protect the patients. Whether you charge for it is up to you, but Host offices are required to have emergency training renewal every year anyway for which they will have to pay someone to do.

Now that we have discussed the common concerns, let’s discuss the different traveling models:

Wisdom Teeth / Implants – This is the easiest model to add for the Host. Treatment plans are simple, patients either want it or don’t. There is no need for consults prior with the surgeon unless the patient wants or there is a specific medical concern. This is the no-brainer add on for travelling dentists. 

Endodontics – This one is simple to set up as well. Easy treatment plans, patients often want to get scheduled, and it is not much of a change from normal GP work for the team. The one concern is patients in pain now and specialist may not be available for a few days, which is simple to solve. Patients are aware of infections and the need for ABs for a few days to clear up infection prior to surgery. Anyone with acute pulpitis the Host can learn to pulp teeth, which should take minimal time. The Host can just refer the patients who cannot wait; but in my experience, they are less than 5%.

For a travelling endo though, retreats make up a huge portion of the work, GPs doing this that aren’t fully comfortable with retreats are going to likely struggle as Hosts are going to have a much harder time keeping them busy. I have had a GP endo in the office for years every week, and he was the easiest Provider to keep busy year-round.

Periodontics – This is a little more complex. There are multiple more codes to manage and patients rarely want perio treatment even though they need it. It still can work out well, but in my experience periodontists do far better with the implant side than the disease side. Consults also are a must in many cases, especially on the disease side, because treatment planning is not as cut and dry as wisdom teeth, implants, or root canals. The upside though is that periodontal treatments are often the highest cost per procedure, so you don’t need as many to make a very busy practice.

Orthodontics – This is the most complex one, only because cases can linger for 1-2 years, unlike every other specialty where your typical case lasts a single visit or up to 3 months. However, it can also be one of the most successful because it can be the most effective at keeping patient retention for the Host. 

Due to the nature of how Ortho works, they must be set a specific day instead of coming as needed. A big concern can be what happens when the orthodontist needs to move, which is why the contract for this needs to be well thought out. This is the one specialty where the idea of having a home office is actually a good idea. Often orthodontists will do this to expand into a new area or town, which can work out very well with far less up-front costs. A home office also provides stability for the Host because they know it is a lot harder for the Provider to just move. And even when a Provider does change, a new one will be there to take their place.

The alternative option is to have the Provider set up a multiple associate model, so they are the ones needing to find replacements when a dentist moves on instead of the Host, which makes this far easier to get offices on board. If you are interested in managing ortho feel free to reach out and I can get you in touch with some people who do this effectively.

How does one setup these models?

The most common arrangement for these is 50/50 split of host to provider. In reality it is just a 50% of adjusted production setup. Often both Provider and Host will split the cost of larger items like implants, bone grafts, membranes, etc.

The host typically provides supplies they normally have (anesthetic, gauze, needles, etc.), chair space, scheduling, collections and insurance management.

The provider typically brings specialist equipment and supplies, as well as their assistants.

If the arrangement above changes with who is providing something, the compensation percentage changes as well. As an example, if the host provided the equipment and assistants, they typically keep 60% instead. The split is all about responsibility, management, and risk.

Conclusion:

I hope this sheds some light on this practice model. I have run this model for 9 years now with a variety of providers across that time. I have seen all the failures and successes, which typically have the same story behind them. An organized Provider is essential to make this model work. The Provider needs to be punctual, highly communicative, and run an organized business in everything from scheduling to billing. The Host needs to realize there is some up-front concerns to manage and to keep an open mind during the process. If both Provider and Host walk into these arrangements with the right attitude, the result is an extreme Win for both dentists as well as the patients.

If you have any questions or concerns about this concept, I would love for you to reach out to me. I fully believe this model is such a win for all involved and expect it to grow in the future that I am happy to help.