Episode #490: The 90-10 Case Acceptance, with Dr. Tarun “T-Bone” Agarwal

Case acceptance should be as high as possible. That's what you've been led to believe. And to challenge that idea, Kirk Behrendt brings in Dr. Tarun “T-Bone” Agarwal, founder of 3D Dentists, with four tips to help you rethink and improve case acceptance. Sometimes, less is more! To learn how to get your patients to say yes more often, listen to Episode 490 of The Best Practices Show!

Episode Resources:

• Dr. Agarwal’s Facebook: https://www.facebook.com/tbonespeaks
• Dr. Agarwal’s social media: @tbonespeaks
• Dentistry Made Simple podcast: https://3d-dentists.com/podcast/
• 3D Dentists 3D Retreat: https://3d-dentists.com/3d-retreat/
• Subscribe to the Best Practices Show Podcast
• Join the To The Top Study Club
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Main Takeaways:

Understand the 90-10.

Give a good, full diagnosis.

Present patients with choices.

Always set firm, financial agreements.

Utilize third-party financing for patients.

Use the three levels of priority scheduling.

Offer dentistry in fewer, well-planned visits.

Quotes:

“I believe we have been massively misled about case acceptance and what case acceptance should be. We’re all led to believe that case acceptance should be as high as possible. And I actually want case acceptance to be around 10%.” (6:00—6:12)

“Here’s what I think happens. We see a tooth, we tell a patient they need a tooth done, and we forget about everything else going on in their mouth. And we never give our patients the chance to say yes to doing all of their dentistry in fewer, well-planned visits.” (6:19—6:33)

“The 90-10 concept comes from this: I want 10% case acceptance. And what I mean by that is, if Kirk came in as a patient and he’s got a mouth full of old amalgams that are starting to break down, I want Kirk to say, 10% of the time, yes to doing everything. But 90% of the time, I want Kirk to say yes to doing at least one area of his mouth. So, it’s a some-or-all concept.” (6:50—7:19)

“I tell patients, ‘You have a right to choose to do some of it, none of it, or all of it.’ So, 90% choose to do some of it. Some people choose to do none of it. And 10% choose to do all of it in fewer, well-planned visits. And that's the premise of the concept.” (7:20—7:36)

“We don't present what people aren't ready to hear, or willing to hear. So, we believe in a nonconfrontational, non-salesy approach to case acceptance. We believe in an influential approach to case acceptance, not an educational approach to case acceptance. And so, we have a four-step process that we teach.” (8:25—8:45)

“The first concept is, I think it’s our ethical obligation to fully diagnose what all is going on in a patient’s mouth. That doesn't mean make up things. That doesn’t mean everybody is a full-mouth rehab. That just means if you looked at this patient and you assume — and this is a big assumption that we have to get through our heads — that money is not an object. We have to diagnose with the assumption that money is not an object. And the second assumption I take is, ‘What would you do if this were your mouth?’” (9:17—9:51)

“We have a fear of overwhelming the patient. We have a fear of hearing “no”. And I think the crutch of the problem is we don't know what we’re looking for. We don't have the diagnostic eyes to see. I'll give you an example. Last week at one of our programs, I put up a picture and I asked all 12 dentists in the room, ‘Put up a treatment plan from this one picture. Assume money is not an object. Assume, what would you do if this were your mouth.’ And the treatment plans ranged from $500 to $30,000. Some people noticed the recession and suggested soft tissue grafting. Some people noticed the malocclusion and suggested orthodontics. Some people noticed the need for a guard. Some people noticed cracks in teeth and wanted to do restorations. So, I think a lot of it starts with, number one, we don't have the eyes of what's going on.” (10:52—11:45)

“Number two, and maybe even more important than number one, is we’re running around on roller skates. We’re literally spending two, three minutes doing all of this and so much has been left to the dentist because we’re the diagnosers. And I believe we’re the confirmers, not the diagnosers. So much of this should be team-driven. But it doesn't become team-driven until it becomes dentist-driven first.” (11:46—12:10)

“All the young dentists I talk to, they're working two, three chairs, plus they're doing hygiene checks. And when I worked like that, my hygiene checks are, ‘We’ll look at that next time. We’ll talk about this next time. Hey, I'm running 10 minutes behind in the next room. Do I really need to see the patient?’ So, we call this phase slowing down to speed up, because we want to get to a concept of one column, one dentist. I don't want our dentists to schedule more than one column of dentistry. That leaves good time to do great hygiene checks. And when you do great hygiene checks, you diagnose more. And then, when you diagnose more, you become more productive.” (12:17—12:58)

“The whole concept of running multiple chairs is to make up for the fact that we’re doing a lot of small things on lots of different patients. And we want to move to a concept of fewer, well-planned visits.” (12:58—13:09)

“We have to prioritize the dentist. It’s got to be dentist first. It’s got to be the name on the door. Even if you're an associate listening to this, you're an entrepreneur within the practice that you're in. That's the beauty of dentistry. You control what you do. You literally call the shots. That's why we went into dentistry. And so many of us got into dentistry to call the shots, and then next thing you know, the inmates started running the asylum and we’re no longer in control.” (14:10—14:39)

“The other day, I got a flat tire on one of my tires on my car. And they said, ‘Hey, by the way, your other three tires are starting to get low on tread. Do you want to proactively go ahead and deal with this, or do you want to come back to us in six months and deal with it?’ And I said, ‘Well, let's just go ahead and deal with all four of them now and be done with it.’ And that's the analogy I like to use with dentists. And ultimately, they didn't tell me I need to replace all four tires. They gave me a choice.” (15:39—16:09)

“When we get to communication, then we start with what's called a permission and choice dialogue. And the permission is, ‘Hey, would today be a good day to talk to you about everything that I see in your mouth?’ And it’s like, ‘Duh, of course. That's what I'm here for.’ And, ‘I want to give you a choice. The choice is, I could talk to you about everything that's going on, and it may sound a little overwhelming, but it'll give you the option to plan out what's going on and get an idea of what's coming up down the road.’ Or, ‘I know that you mentioned you were having pain down here. If you’d like, we can just focus on this one area. Which works best for you?’” (16:10—16:48)

“People feel sold to when you tell them what they want, or you choose for them. And so, to me, everything is about giving the patient the choice. It’s your teeth. It’s your mouth. Frankly, I don't care what you do. I legitimately don't care what you do. So, the first step is, we’ve got to give them permission and choice.” (17:04—17:22)

“I want to give every patient a chance to do something like this: ‘If it’s possible, would you be interested in getting all your dentistry done in as few as a single visit?’ And what patient says, ‘No, I'd rather come back to the dentist eight times’? Nobody. Right? So, I frame it as, ‘Would you be interested in trying to get all your work done in a single visit?’ And I know the dentist is out there saying, ‘Well, what if it can't be done in a single visit?’ Then don't offer it in a single visit. Say, ‘In as few visits as possible.’ Because not everything can be done in one visit. But the premise is, I want [patients] to say, ‘Yes, I want to get it done in a single visit.’” (17:42—18:25)

“I want to start with diagnosing everything I see in the mouth as if it were my mouth. I want to ask the patient, do they want to hear about everything, or do they want to focus on just a single area. And then, I want to ask them, ‘Would you like to do everything in as few visits as possible.’ And the typical patient is going to say, ‘Of course I would. But how much does it cost?’ And then, we get to block number three, which is our firm financial arrangements. And this is where most people have dropped the ball. They diagnose, they give patients the chance to say yes, and then patients say no because they can't afford it. And then, we get retrained, instead of presenting with $3,000 of dentistry, let me just present with what insurance will cover. And that's why I need 3,000 patients, because I need 3,000 patients to do $400 worth of dentistry for me to make a living.” (19:18—20:19)

“Let's walk through box number three, firm financial arrangements. Our concept here is that, in our practice, we make a simple promise to our patients. Before we ever begin, we’re going to give you, in writing, what we’re doing, how long it’s going to take, how much it costs, and exactly how you can pay for it — in writing. And that's our financial menu.” (21:07—21:33)

“Patient affordability has very little to do with price.” (21:40—21:43)

“Patients aren't saying no to the dentistry. They're saying, ‘No, you haven't provided me a way to fit it into my budget.” (23:09—23:15)

“An amazingly underutilized service in every practice is the use of third-party financing. Payment plans. How do we make this affordable? Payment plans are all about affordability. At the end of the day, a $1,500 crown is super expensive. A $2,000 crown is super expensive. A $1,000 crown is super expensive. It doesn't matter. It’s all a lot of money to the average person in this country. So, the firm financial arrangement starts with the concept of a financial menu.” (23:18—23:49)

“Imagine if you went to a restaurant and every waiter or waitress had to tell you what's on the menu. How much would you buy? It'd be tough, right? But what do they give you? They give you a menu in writing that spells out exactly what they offer and exactly how much it costs. So, our concept starts with a financial menu that tells the patient exactly what we’re doing, how much time it’s going to take, exactly how much it costs. And then, the kicker part of it is exactly how they can pay for it. And exactly how they can pay for it is two categories. Category number one is you can pay in full. Category number two, you can choose payment plans.” (23:50—24:35)

“You're going to give away anywhere between 5% and 14% cost of the practice, depending on the patient’s credit worthiness. So, let's average it out and say it’s 9% to 10% I'm going to give away. So, if we do simple math, if using a third party allows me to do two crowns at the same time on a patient versus one crown, your profit margin goes from 10%, 15% to 40%, 50%. Because how much longer does it take to do two crowns versus one crown? And so, the margin is not in the savings of the discount fee. The margin is in doing more dentistry in a single visit. That makes up for the 10%.” (26:18—27:03)

“Car dealerships are selling more cars than you need to people that shouldn't be able to afford that car, because they're doing something right. So, for me, it really boils down to, you've got to forget about the discount fee. And it starts with giving the patient the chance to say yes to all of it. And then, you have the financial menu in place so the patient can choose what they want to do. So, I want the patient to choose. And what we have found is that we work on less patients and we get a great result, and everybody wins.” (28:35—29:13)

“I talk about the financial arrangements. It’s firm financial arrangements. And what I mean by that, you do not get on our schedule until you sign and leave a deposit . . . Remember, I said there are two choices. Choice number one is you're paying full. Choice number two is you choose a payment plan. If you choose a payment plan and it’s a third-party service, great. Get approved, we’ll schedule you. You're approved for the money. We’re going to get the money. We run your care credit, X, Y, Z company, and we get the money, we schedule you, we put all your appointments on the books and knock it out. If you say, ‘Hey, I'm going to pay at the time of service,’ then we handle it this way. You leave a $100 deposit to get on the books, and then you owe the rest of it the day of service.” (29:30—30:31)

“For our sedation cases or our super-large cases that are three, four, five hours long, we take a larger deposit. But again, most dentists aren't doing lots of three, four, five-hour dentistry. So, let's keep it simple and focus on the 30-minute to two-hour appointments. Take a $100 deposit. It’s enough money to make people say, ‘Well, I'm not really committed. I don't want to schedule right now.’ And that's what I want. I don't want anybody to schedule that's not committed. Again, the clues are all around us. You do not get an airplane reservation without paying for your seat.” (30:34—31:05)

“Here’s why you need it in writing. 70% of your patients don't say yes right away. A lot of people say, ‘Hey, I've got to go home and think about it,’ or, ‘I'm not ready to decide. I've got to look at my calendar. I've got to think about it.’ And if you didn't do this in writing, then they don't remember how you told them they can pay for it. So, the in-writing part is all about something they can keep in their drawer, something they can refer back to and they can say, ‘Oh, my tooth is hurting. I need to get this taken care of. A month ago, I went through this. Let me look at my treatment plan. I need to choose this. Let me get this done.’” (31:18—31:52)

“The other part about in-writing is, there's something psychological about having somebody sign something and getting it in writing that they committed to this. And so, to me, it’s about the psychology of it. And I don't want people calling us back and saying, ‘Hey, I remember you talked about payment plans. What were my choices, again?’ Just give it to you in writing.” (31:53—32:12)

“I'm going to make up numbers here. I want to produce a million dollars. I want to produce a million dollars with one patient in one day. That's my goal. It’s impossible. I get it. But why should I see 1,000 patients to do a million dollars when I can see 100 patients to do a million dollars, or 500 patients to do a million dollars?” (33:06—33:23)

“I don't like running from room to room, bottom line. Because, for me, running from room to room means I've got to have more team members. I've got to have a bigger facility. I've got to have more operatories. I've got to create a big machine where it suddenly turns into, I'm working to feed the machine, and I get whatever may be left over, and you feel like you're working for everybody else. To me, I don't want any of that. I went into dentistry to call the shots, so I want to keep it simple.” (33:27—33:57)

“Our concept on the scheduling is a column per provider on the schedule. So, in your practice management software, there's a column per provider. Now, that may mean I work out of two rooms to most efficiently see my patients while the other room is getting set up or torn down. But in the schedule, it’s one column per provider. Most people, what they're doing is they're making a column per chair. And that's when chaos starts. It turns into utter chaos.” (33:58—34:28)

“I'm an eight-operatory practice. Most people would have eight columns in their practice management software of choice. In our practice, we’re three hygienists, three dentists, and one other. We have seven columns in our office because we have seven providers, because a provider cannot be scheduled to be in more than one place at a time. Now, I may work out of multiple rooms. But not with multiple patients in multiple rooms at the same time.” (34:34—35:01)

“The clues are all around us. I learned this in the medical/surgical model. For example, when you go to a plastic surgeon, they say, ‘I do consults on Tuesdays, and I do surgeries on Monday and Wednesday.’ And what do patients that want plastic surgery do? ‘Well, I guess I'll get my breasts done on Monday or Wednesday,’ because that's the day I've set up for the surgeon to do that type of procedure. So, I take that mentality for my part of the practice.” (37:08—37:38)

“Our concept is what we call priority scheduling. And there are three levels to it. Level one is your traditional block scheduling, what's been taught since the ‘80s, ‘90s, whatever. I think it’s antiquated, personally, but it’s the traditional model. And the block scheduling is rock, paper, scissors; rock, sand, water, whatever it is, and you block production waste. So, we have rock, procedures that are, in our practice, $2,000 or more. You have sand, procedures that are $300 to $500. And you have water procedures that basically pay you nothing. That's a great starting point. So, if your schedule is a free-for-all where patients can choose when they go, a great place to start is what we call level one scheduling, which is your traditional block schedule.” (38:24—39:16)

“Once we get control of our traditional block scheduling, the next concept is a time-based concept. And that's a time based for a single patient. So, again, we stick to the block concept. But what we do is we block four-hour blocks, three-hour blocks, and two-hour blocks for one patient at a time. So, a patient that needs four hours’ worth of work, a patient that needs three hours’ worth of work, and a patient that needs two hours’ worth of work. And we have multiple blocks depending on your historical data of what type of dentistry you're doing, and we block that many patients.” (39:44—40:18)

“Level three is what we call procedure or bust. For example, in my scenario, the second Wednesday of every month is a hybrid. If we don't have a hybrid that month, I don't work.” (42:22—42:35)

“It’s your name on the door. You should be controlling and calling the shots. So, there's nobody that says you have to do it my way. You don't have to do it Kirk’s way. You don't have to do it anybody’s way. You have to do it your way. It’s your name on the door. It’s your business. You're the one that spent half a million dollars getting through school. You're the one that took out the million-dollar loan to do this. You're the one that's responsible for anywhere from four to 15 people and their families, and them making payroll, and your own family. It’s your name on the door.” (44:36—45:08)

“If you're not a practice owner and you're an associate, you control and own your operatory. Your ability to earn is directly related to what you diagnose, how you communicate it, how you make it affordable for people, and how you run your schedule in the practice.” (45:08—45:22)

“At the end of the day, the most effective way to learn anything is to get the hell out of your home, completely focus on what you're doing, and get around other like-minded individuals. Something magical happens when you're around people and start talking to people. Or, even if you don't like to talk to people, something magical happens when you sit in the corner and listen to other people talk. Amazing things happen.” (46:25—46:46)

Snippets:

0:00 Introduction.

1:50 Dr. Agarwal’s background.

4:21 3D Dentists 3D Retreat.

5:43 The 90-10, explained.

7:53 Step one to case acceptance: good diagnosis.

10:22 Why low diagnosis is a problem.

13:09 Step two to case acceptance: give patients choices.

18:26 Barriers when offering as few visits as possible.

20:57 Step three to case acceptance: firm financial arrangements.

25:49 Why you want to utilize third-party financing.

27:13 Financing can be a big percentage of revenue.

27:54 Should doctors talk about fees?

29:15 Step four to case acceptance: priority scheduling.

31:08 The importance of having things in writing.

32:40 Dr. Agarwal’s philosophy on scheduling.

34:28 Have one column per provider.

35:10 What Dr. Agarwal’s schedule looks like.

36:15 Having clarity around goals.

37:38 Priority scheduling, explained.

43:10 Be firm in principle, flexible in procedure.

44:14 Last thoughts on the 90-10.

45:36 More about Dr. Agarwal’s podcast and courses.

Dr. Tarun “T-Bone” Agarwal Bio:

Dr. Tarun Agarwal is a recognized speaker, author, and dental leader. He has been featured on CBS, NBC, ABC, FOX, and News 14 Carolina. He has been awarded ’40 Under 40’ Business Leaders by the Triangle Business Journal. He is the founder of 3D Dentists and Raleigh Dental Arts.

Most importantly, he is a loving husband and dedicated father of three wonderful children. His biggest accolade was being voted ‘Best Dad in the World’ by two of his three kids.