Are we slowly losing control of our profession?
This is a guest post by Dr Chris Riolo who is a full-time specialist orthodontist in Seattle, USA. He discusses one way we can begin to take control of both our workflow and data using in house aligners facilitated by our professional organizations. It is a very interesting and ambitious viewpoint.
Digital orthodontics and Computer-Aided Design (CAD) technology, in combination with subtractive and additive manufacturing technology, have the potential to be a transformational force for good in the care of our patients.
Unfortunately, up until now, these disruptive technologies have benefited only corporations that focus on market share and profits, not patient care. One of the consequences of these technologies is the rise of corporate “providers”, i.e. Invisalign, Smile Direct Club, Byte (Now Dentsply Sirona) and Candid Co.
Today, dental corporations are commanding a higher and higher percentage of “practice revenue” as they enter the doctor-patient relationship. They use a myriad of tactics to increase their influence on our practices and the relationship we have with our patients:
1. Direct to Consumer Marketing:
In some cases, the patient is treated without the supervision of a dentist, let alone an educationally qualified orthodontist. Frequently, essential safeguards, including initial radiographs or documented pre-treatment periodontal and caries clearance, are absent. Instead, the responsibility for treatment readiness is placed on the patient.
2. Direct Corporate Referrals:
Corporations now frequently refer patients directly to select providers through online portals or storefronts. As the percentage of patients received and started by a particular provider increases, the relationship between the orthodontic provider and the corporation begins to blur. When the referrers objective is to sell a specific product or appliance, who dictates the treatment plan? Provider or Corporation? This move, in effect, makes all of us their unpaid sales force.
3. Tiered Pricing:
Corporations commonly employ tiered pricing to influence orthodontists to treat patients with a particular appliance system. These pricing tiers are now the rule rather than the exception. The Orthodontist is “encouraged” to start a certain number of patients every quarter.
If the Orthodontist makes the next tier, they can save hundreds of dollars for every patient started the next quarter. Importantly, when the Orthodontist is “just a few starts” away from the next level, the implicit pressure is to push a few more patients into aligner treatment that the clinician would instead start with fixed appliances. The cost to the orthodontic practice of ignoring this tiered pricing scheme can be thousands of dollars each month.
One company has taken tiered pricing to a new level with select practices offering “unpublished pricing discounts” to high volume practices that “open their books” to guarantee that a PERCENTAGE of the patients will be started with the company’s product! In addition, these corporations are merging/consolidating and are beginning to bundle “products”. So, for example, the cost of your practice next scanner may well depend on the number of patients you commit to starting with the company’s product.
4. Corporate Education:
Corporations are holding their own “educational” meetings; they have “faculty”. And why not? The corporations are gathering the data and doing most of the research on these new appliance systems. But, of course, they do not share this data with the public; the evidence is presented back through their “Key Opinion Leaders” (KOL’s- Orthodontist paid to endorse/ influence) and their own “educational” events as well as large corporate dental meetings. These corporations initially use orthodontists to “train” their Artificial Intelligence (AI) programs by collecting massive amounts of treatment data. The AI programs are then used to power the company’s software.
5. Proprietary Data:
Private Insurance companies have been collecting data for years. However, the amount of data available for collection has exploded due to the advent of digital orthodontics, and the data is far more granular in detail. It is not a coincidence that almost every major company collects data; to a greater and greater extent, in this new economy, data is power, data is money. If our professional organizations ignore this fact, they are destined to become insignificant like their counterparts in Medicine.
The encroachment of corporate dentistry into our profession and our relationship with our patients is most evident in North America and the United States in particular. Nevertheless, these corporations are multinational, and so are these trends. This issue sounds very grim for the orthodontic profession, but disruptive technologies cut both ways. Digital design paired with 3D printing of resin and metal has the potential to disrupt centralized manufacturing. We can now make custom orthodontic appliances like Incognito and Invisalign locally in our own offices rather than in multi-building manufacturing facilities located globally. The future of our profession lies in taking control of our Data and our Workflow, as opposed to relying on multinational corporations for our custom appliances and at the same time ceding all our data.
First steps towards a reimagined future?
It is clear that we have a problem; what is the solution? I believe the answer is for educationally qualified orthodontists to stand together to benefit our patients and our speciality. Our power lies in our participation in organized dentistry through organizations like the AAO, EOS, and WFO.
I will outline one obvious solution; companies like Invisalign, Smile Direct Club, Byte and Candid spend hundreds of billions of dollars branding themselves. They do this to develop the market share that a large professional organization like the AAO, EOS and WFO could command on day one. If a large professional organization acquired or developed aligner staging software, it could change the whole trajectory of our profession. All orthodontists will soon own and operate 3D printers daily; all orthodontists can create a thermoform aligner in house using a Biostar, Drufomat or the equivalent. All we lack is cloud-based staging software to provide our patients with affordable aligner treatment. Whether this would be limited, comprehensive, or hybrid therapy in conjunction with fixed appliances.
Importantly, I am not proposing that orthodontists exclusively provide in-house appliances to our patients. Instead, I suggest that we provide affordable and flexible treatment when it benefits our patients. When we deem it is better to employ a commercial system, we will have that option. But these corporations will have to compete honestly for the privilege of participating in our patients’ care.
Let us consider the consequences of implementing this scenario:
1. A new player:
Orthodontists themselves would overnight become a major player in the multi-billion-dollar aligner market. These commercial companies spend fortunes on branding and advertising for patients. Orthodontists, as a community, are the market that they are trying to tap. We already have what these corporations are spending hundreds of millions of dollars to develop; we are the market share. The professional association that develops staging software 100% owned and controlled by its membership will become a significant player in the aligner marketplace overnight.
2. Reverse Declining Membership In Organized Dentistry:
The strength of any professional organization is membership; to maintain and grow membership, an organization must provide value. Our power is in the numbers; it is imperative that no matter which professional organization develops cloud-based staging software, it should be made available to any “educationally qualified” orthodontist in the world. By allowing the use of the software to an orthodontist who is a member of their local or international professional organization, we add value to all professional organizations, not just the organization that developed the software.
Consider the consequence of providing unlimited use of aligner staging software for only $100 per month to any educationally qualified orthodontist who is a member of organized dentistry in their country. Just 10,000 member users would generate $12,000,000.00 per year for continued development and improvement of the software. We could easily see more than double that number of member users worldwide. In Nepal, the average orthodontic fee ranges from $350 to $1150, depending on the appliance system employed. Access to this staging software through an orthodontist’s local organization would add tremendous value to the membership not just for the North American or European Orthodontist but for member orthodontists worldwide. Importantly, access to affordable staging software will likely reverse the recent declining participation in organized orthodontic associations in North America. The more membership increases, the greater our power in the orthodontic marketplace.
3. Funding The Future:
“Non Dues Revenue” gets the attention of any orthodontic organization. The professional organization that foresight to provide this service will also have access to the excess revenue generated. We can use this type of staging software to offset member dues and essential projects like an Orthodontic Registry. We generate vast amounts of digital data in our offices through the process of treating our patients. These data have to be systematically collected and collated into an orthodontic registry that could be invaluable, making our profession leaders in evidence-based care. Developing the means to collect, store, and interact with these data is the first step in controlling our data for the good of our patients and the profession and implementing cloud-based staging software does precisely that.
Two important guiding principles
For organization based staging software to be successful and have the intended effect on our profession, we must adhere to two important guiding principles:
First, the software must be cloud-based and 100% owned and controlled by the professional organization’s membership. Second, any educationally qualified member of a legitimate orthodontic professional organization should be able to participate.
The first principle addresses the need to control our DATA and our WORKFLOW; the second principle acknowledges that we need to stand together as a profession. Many of these corporations are international, and we cannot afford to be fragmented. We are all orthodontists facing similar challenges. If we stand together, we all benefit.
Nobody is better positioned than professional orthodontic organizations like the AAO, EOS or the WFO to disrupt the orthodontic marketplace. We do not have to be victims of the changes we are now seeing. We can be the disruptors! We have to act; the first step will be the hardest, convincing our leaders to think outside the box and work to preserve our profession. Orthodontists value a marketplace that allows the flexibility to treat patients affordably with the tools to address patient needs and desires. It is not factories and distribution systems alone that command power in this new marketplace; it is SOFTWARE and DATA. Software and data are power, and organized orthodontics is uniquely positioned to leverage this power to benefit our patients and our speciality.
The way forwards
We need to act now; what can you do? First, talk to your colleagues and contact your representative in your respective professional organizations. Emphasize the value that a staging aligner software would bring to you, your practice, and your patients. Discuss the vast benefits of collecting and analyzing data on the orthodontic profession and its ability to deliver independent and evidence-based care. Tell them that without adding value to membership in our professional organizations, it will be tough to convince the next generation of orthodontists that membership in their professional organization has more value than an excellent orthodontic Facebook group.
A version of this post was first published by the AJO-DDO.
Emeritus Professor of Orthodontics, University of Manchester, UK.