Sept. 3, 2026
Who Gets the First Vote? Clinical Judgment, Coverage, and Learned Helplessness
Clinicians are trained to answer one question: What does this patient need?
But once they enter practice, another voice often enters the room: What will insurance cover?
The problem is not that coverage exists. The problem begins when coverage gets the first vote.
In this episode of The Operator, Jimmy McKay and Larry Benz examine how clinicians can gradually learn to reshape their judgment around payer rules without anyone explicitly instructing them to do so.
Larry connects the issue to learned helplessness: when decisions are repeatedly overridden by portals, fee schedules, denials, and coverage limitations, clinicians can eventually stop exercising independent judgment before checking what the system will allow.
But Larry also turns the responsibility back toward healthcare operators. If organizations onboard clinicians with little more than a schedule, production target, and benefits portal, they are helping create the behavior they later complain about.
Key ideas from the episode:
- Why newer clinicians may be technically capable but short on repetitions
- How lower repetition leads to lower clinical confidence
- Why “here’s your schedule, go produce” is not development
- Why human capital should be treated more like CapEx
- How structured mentorship and deliberate practice can close the readiness gap
- Why clinicians gradually learn to let coverage shape treatment
- What learned helplessness looks like inside healthcare
- Why outsourcing treatment conversations can weaken clinical judgment
- The three questions Larry believes should guide treatment decisions
- Why the order of those questions is the intervention
- How stronger clinical confidence can improve case acceptance, referrals, and long-term economics
- The difference between compounding human capital and renting growth
Larry’s framework is simple:
1. What does the patient need?
2. What will coverage support?
3. How do I have that conversation?
Coverage matters.
It just should not answer the first question.
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WEBVTT
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All right,
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we spend years training clinicians to make
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good clinical decisions.
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Then they get into practice and another
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voice enters the room.
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What will insurance cover?
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And somewhere along the way,
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that question can start getting asked
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before,
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what does this patient actually need?
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Larry's latest article said that this
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isn't just a payer problem.
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Operators maybe have their hands dirty.
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Maybe they helped build it.
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So let's start by asking this.
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Larry, you start by saying, you know,
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new clinicians are arriving less
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clinically ready than they used to.
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You're careful to say it's not an
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indictment on dental education.
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So then what's sort of changed?
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Yeah, I think, you know,
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Jimmy,
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this is a little bit of a hangover
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from COVID or that actually occurred
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during COVID,
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but fundamentally two things changed and
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only really one of them ever gets talked
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about.
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The structure changed, you know,
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fewer patient volume hours,
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were necessary to graduate.
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So that means you get less procedural
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diversity and you get maybe a little bit
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of earlier specialization is the other
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factor.
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So less reps effectively.
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So they come out,
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the new grad and this traverses
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everything, right?
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They come out technically capable,
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but short on repetition.
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And when you have short on repetition,
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you have short on confidence.
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And really confidence you can only get
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through volume.
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So it becomes a cycle.
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So you can't blame the student.
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Blaming the student is like blaming the
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teenager, you know,
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for being a shaky parallel parker.
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If you had a parallel park when you
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were driving, right?
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Yeah.
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The second thing that changed is nothing.
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And that's the problem.
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We didn't change.
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We still hire like it's nineteen ninety
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five.
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Right.
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Week one.
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Here's your schedule.
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Here's the production target.
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We built our expectations around a
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graduate graduation.
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effectively stopped existing years ago.
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And so, as I said,
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I've seen the same thing happen in
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physical therapy for four years.
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Every clinical profession that compresses
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hands-on hours produces the same graduate,
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smart, credentialed, but under repetition,
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therefore lack of clinical confidence.
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Dentistry isn't anything special.
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It's just sort of late to admitting it.
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Yeah, yeah.
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You've said these clinicians enter
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organizations that want them to also do
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this, be productive quickly.
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This feels like putting dysfunction on
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instability.
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How are most platforms trying to close
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that gap?
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Like, you know,
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what's wrong besides the obvious on that
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approach?
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Yeah,
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so the implications of high clinical
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shortages, less therapists, less dentists,
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less doctors,
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is that you become very efficient in
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onboarding.
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You give them a checklist and a production
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target.
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That's sort of the industry's answer.
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And I wish I was exaggerating.
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You get orientation,
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maybe a tour of the break room,
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maybe some shadowing,
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but the idea is go produce.
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You've got a salary.
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We're paying you higher than we ever have.
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Go produce.
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That's not development.
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That's hope with a paperwork, right?
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What's wrong with it is that it treats
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clinical readiness, which is a problem.
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It treats it as a scheduling problem.
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And so the dental company of the future,
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the physical therapy company of the future
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builds an actual infrastructure.
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Mentorship,
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simulation was real common in dentistry
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now, structured case review,
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deliberate practice.
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That's the big buzzword.
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And yes,
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overhead does rise before productivity
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shows up.
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So you have to think of human capital
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as an investment,
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like you were buying a piece of equipment
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or a modality in physical therapy
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language.
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you know, I won't pretend it's otherwise.
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And so human capital is an investment and
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it's cap X.
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And you have to understand that you're
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going to get less productivity and you
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have to model it that way.
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But the multiplier on the other side of
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this retention engagement,
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better procedure mix, better referrals,
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you know, that's unambiguous.
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It's very objective.
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And the benefit is to the company
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downstream.
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Yeah.
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Yeah.
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Well, you've done something about this.
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At DCA,
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you've actually built something called
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Ascend,
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which you described as almost like a
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residency for general dentists,
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for general practitioners.
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What are you trying to create that maybe
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an ordinary onboarding or mentorship
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doesn't?
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Yeah.
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So I did this same playbook in physical
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therapy where we had the initial
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certification programs.
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These are best thought of as not short
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term weekend courses, but longer term.
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Then those became residencies.
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Physical therapy became accredited
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residencies.
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We have those in dentistry as well,
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but they're a lot more profound and a
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lot more accreditation risk.
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And so what we do now is develop
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a curriculum.
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And if you think about it,
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ordinary mentorship depends on entirely
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where the dentist or the therapist lands,
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right?
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Maybe there's a great senior therapist or
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doctor there.
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And if that happens, you flourish.
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So what Ascend is,
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is really a certification pathway.
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It's advanced training for a general
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dentist
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to get upskilled in endodontics,
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orthodontics, restorative.
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Medicine decided a century ago that a
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residency is how you turn a graduate into
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a physician.
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And dentistry sort of is winging it,
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for lack of a better term.
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It's interesting.
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The Army taught me this well before
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dentistry did.
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Nobody in the military hands you a mission
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without a training pipeline behind it.
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But in dentistry, we have a mission.
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But we basically say to the dentist,
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figure it out.
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And getting upskilled is expensive.
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And you've already got somebody who's got
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a lot of student debt.
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The good news is like in a general
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GP, a general practitioner in dentistry,
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a general dentist has a very liberal
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practice act.
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In healthcare,
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I can never get my primary care docs
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to deliver a baby or to do orthopedic
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surgery.
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But in dentistry,
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a general dentist can do orthodontics,
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oral surgery, endodontics, periodontics,
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and can do it rather well.
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Now,
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there's a defined line of what they can't
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do.
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But they can be upskilled.
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And so in order to do that, though,
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you have to have training.
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What is training?
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Training takes investment,
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investment in human capital.
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Again,
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we think of de novos and equipment and
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space and build outs.
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We have to start thinking of our human
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beings under those same investment thesis.
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Yeah.
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Well,
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here comes a sentence that brings somebody
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else back into the room.
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We're training a clinician to let a payer
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make clinical decisions.
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That's serious.
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That's some hot take, right?
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So how does a clinician get trained to
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do that without anyone ever explicitly
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teaching them to do that?
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Yeah,
00:07:04.913 --> 00:07:06.752
so all these things sort of happen by
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default.
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We send a default to what the payer
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does.
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But if you think about it in dentistry,
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it's a little bit worse because the
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dentist will say to a patient, OK,
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go now talk to our treatment coordinator
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who will talk to you about our insurance.
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So we outsource the decision making to
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somebody who's not even a clinician.
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And that's just absolutely wrong,
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you know.
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A plan gets, think about it,
00:07:35.797 --> 00:07:37.877
a plan gets denied in dental or
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healthcare.
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A code gets downgraded.
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Something happens with a write-off.
00:07:43.978 --> 00:07:46.959
And all we tend to do then is
00:07:47.000 --> 00:07:49.620
just kind of default and we train this
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into our system rather than just
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fundamentally understanding that the
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clinician should be having the discussion
00:07:56.242 --> 00:07:57.084
with the patient.
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The payer should be secondary to all that.
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I refer to all this as learned
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helplessness.
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As you remember,
00:08:06.201 --> 00:08:08.983
I've got a degree and master's of applied
00:08:09.043 --> 00:08:10.324
positive psychology from University of
00:08:10.363 --> 00:08:12.505
Pennsylvania where Marty Seligman,
00:08:12.526 --> 00:08:15.507
you know, Angela Duckworth,
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all those luminaries teach.
00:08:18.709 --> 00:08:20.511
And Marty Seligman really was the
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researcher who in the nineteen sixties,
00:08:22.892 --> 00:08:24.874
well before there was optimism,
00:08:25.495 --> 00:08:27.475
defined learn helplessness,
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which is the idea that no matter what
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I do, what I respond to,
00:08:31.538 --> 00:08:33.059
it doesn't impact the outcome.
00:08:34.251 --> 00:08:37.094
And when you can't impact the outcome,
00:08:37.514 --> 00:08:38.774
you learn to be helpless.
00:08:39.434 --> 00:08:41.235
And that's what's effectively happened in
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healthcare.
00:08:41.775 --> 00:08:44.457
A clinician whose judgment keeps getting
00:08:44.638 --> 00:08:46.578
overruled by a portal,
00:08:47.259 --> 00:08:48.340
an insurance portal,
00:08:48.379 --> 00:08:50.441
stop exercising the judgment.
00:08:50.461 --> 00:08:53.182
And so the portal doesn't have to win
00:08:53.201 --> 00:08:54.082
the argument anymore.
00:08:54.123 --> 00:08:55.403
There is no argument.
00:08:56.063 --> 00:08:56.845
In physical therapy,
00:08:56.884 --> 00:08:58.265
this happens a bit as well.
00:08:58.326 --> 00:09:00.648
It's just that our codes are more
00:09:00.727 --> 00:09:01.508
scrunched in.
00:09:02.269 --> 00:09:02.928
They're fewer.
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They're not as diverse and there's not as
00:09:04.931 --> 00:09:08.854
many procedural-driven expensive codes.
00:09:09.875 --> 00:09:11.355
And what happens in dentistry, again,
00:09:11.395 --> 00:09:13.076
is we just sort of outsource all this
00:09:13.116 --> 00:09:15.759
because we learn we shouldn't be doing
00:09:15.779 --> 00:09:15.899
that.
00:09:15.940 --> 00:09:18.000
The reality is those conversations should
00:09:18.140 --> 00:09:20.243
absolutely be happening between the
00:09:20.283 --> 00:09:22.164
clinician and the patient.
00:09:23.195 --> 00:09:26.376
You painted this recognizable scene that I
00:09:26.437 --> 00:09:28.138
think many people in healthcare have
00:09:28.238 --> 00:09:28.859
walked through,
00:09:28.918 --> 00:09:29.940
and maybe you never named it,
00:09:29.960 --> 00:09:32.500
but the clinician knows what the patient
00:09:32.541 --> 00:09:32.922
needs.
00:09:33.501 --> 00:09:34.942
They then open the benefits portal,
00:09:35.023 --> 00:09:35.903
and then all of a sudden,
00:09:35.923 --> 00:09:37.004
without anybody telling them to,
00:09:37.043 --> 00:09:39.025
the treatment plan then bends.
00:09:39.346 --> 00:09:40.726
It shifts.
00:09:40.746 --> 00:09:42.347
What's sort of happening in that moment?
00:09:42.368 --> 00:09:43.447
You've touched on it a little bit,
00:09:43.489 --> 00:09:44.568
but what's going on there?
00:09:45.190 --> 00:09:46.730
Yeah, so the judgment comes first,
00:09:46.770 --> 00:09:47.850
and it's very real, right?
00:09:47.890 --> 00:09:49.192
They see the right answer.
00:09:49.812 --> 00:09:51.774
Years of training are pointing at it.
00:09:52.198 --> 00:09:53.744
Then the portal opens up and the plan
00:09:53.825 --> 00:09:55.671
reshapes itself around the coverage.
00:09:56.481 --> 00:09:57.602
And what does it cover and what does
00:09:57.643 --> 00:09:58.283
it not cover?
00:09:58.342 --> 00:09:59.283
Nobody orders it.
00:09:59.783 --> 00:10:01.445
And here's what makes it dangerous from
00:10:01.465 --> 00:10:02.005
the inside.
00:10:02.046 --> 00:10:03.947
It never feels like surrender.
00:10:03.966 --> 00:10:05.408
It feels like being realistic,
00:10:05.447 --> 00:10:07.229
being practical, being a team player,
00:10:07.668 --> 00:10:09.509
trying to be patient centric,
00:10:09.549 --> 00:10:10.990
understanding what they have and what they
00:10:11.030 --> 00:10:11.292
don't.
00:10:12.011 --> 00:10:12.652
Well, in dental,
00:10:12.792 --> 00:10:14.113
there's not true underwriting and
00:10:14.173 --> 00:10:14.793
insurance.
00:10:15.533 --> 00:10:20.096
And really the conversation has to sort of
00:10:20.717 --> 00:10:22.219
happen between the patient and the
00:10:23.099 --> 00:10:23.740
clinician
00:10:24.767 --> 00:10:27.128
and then you know secondarily to that
00:10:27.227 --> 00:10:28.448
whatever insurance covers whatever
00:10:28.489 --> 00:10:30.250
insurance covers right but it's not just
00:10:30.289 --> 00:10:33.890
generally how it works um and so you
00:10:33.910 --> 00:10:35.692
know no dentist in america has ever
00:10:35.751 --> 00:10:38.253
written surrender to the fee schedule in a
00:10:38.312 --> 00:10:40.793
note the chart says the patient elected
00:10:40.833 --> 00:10:43.655
alternative treatment the language is the
00:10:43.716 --> 00:10:46.037
thing that that that launders the moment
00:10:46.860 --> 00:10:48.600
Now there's a data point in dentistry
00:10:48.640 --> 00:10:50.702
called treatment case acceptance.
00:10:51.143 --> 00:10:54.205
That's the number of patients who accept
00:10:54.446 --> 00:10:56.527
what the treatment case is supposed to do.
00:10:57.488 --> 00:10:58.568
Believe it or not, Jimmy,
00:10:58.589 --> 00:11:00.629
that number hovers between fifty and
00:11:00.669 --> 00:11:02.772
seventy five percent.
00:11:02.792 --> 00:11:04.952
The reason it happens that way is because
00:11:04.993 --> 00:11:06.835
of learned helplessness, in my opinion.
00:11:07.559 --> 00:11:10.701
We never really have the clinician have a
00:11:10.760 --> 00:11:11.701
conversation.
00:11:11.881 --> 00:11:13.341
It goes and it gets outsourced.
00:11:13.682 --> 00:11:15.582
When that conversation gets outsourced,
00:11:16.263 --> 00:11:17.884
that percentage doesn't go up,
00:11:17.923 --> 00:11:19.823
it goes down in my view.
00:11:19.903 --> 00:11:19.984
Now,
00:11:20.024 --> 00:11:21.144
there are a lot of practices that would
00:11:21.184 --> 00:11:21.684
disagree.
00:11:21.705 --> 00:11:22.004
They say,
00:11:22.044 --> 00:11:23.846
I don't want the conversation between the
00:11:23.885 --> 00:11:24.926
dentist and the patient,
00:11:24.946 --> 00:11:26.366
but I don't see it that way because
00:11:26.407 --> 00:11:28.807
I think these are clinical issues and not
00:11:28.868 --> 00:11:29.687
insurance issues.
00:11:30.207 --> 00:11:31.009
Yeah.
00:11:31.048 --> 00:11:31.168
Well,
00:11:31.188 --> 00:11:32.208
from what I know about you is you
00:11:32.229 --> 00:11:33.950
try to not make anything a blame game.
00:11:33.990 --> 00:11:35.270
This is where I think in your article,
00:11:35.331 --> 00:11:37.292
you turn sort of the responsibility or the
00:11:37.412 --> 00:11:39.673
accusation towards ourselves, right?
00:11:39.693 --> 00:11:40.835
This is the only thing we can control.
00:11:40.855 --> 00:11:41.875
You're talking about learned helplessness.
00:11:41.894 --> 00:11:43.355
Well, what can we control?
00:11:43.436 --> 00:11:44.616
In the article, you said, well, listen,
00:11:45.136 --> 00:11:46.677
the operators, you signed off on it.
00:11:48.038 --> 00:11:49.240
Okay, where did we sign?
00:11:49.259 --> 00:11:51.620
So that's probably the big question.
00:11:52.221 --> 00:11:52.522
You know,
00:11:52.881 --> 00:11:54.462
where did we sign on for this?
00:11:54.582 --> 00:11:54.962
When?
00:11:55.202 --> 00:11:55.964
How did that happen?
00:11:58.313 --> 00:12:00.937
Yeah, I would say it's how we train.
00:12:00.957 --> 00:12:02.379
I mean, that's the signature.
00:12:03.280 --> 00:12:06.684
No operator ever wrote a memo handing the
00:12:06.745 --> 00:12:07.846
payer the final word.
00:12:08.567 --> 00:12:10.009
We do something a little bit quieter.
00:12:10.682 --> 00:12:10.842
You know,
00:12:10.863 --> 00:12:12.784
we built a development program to teach
00:12:12.845 --> 00:12:14.626
everything except judgment under coverage
00:12:14.667 --> 00:12:15.967
pressure, right?
00:12:16.048 --> 00:12:16.567
Think about it.
00:12:16.707 --> 00:12:19.291
We should be teaching clinicians judgment
00:12:19.431 --> 00:12:20.652
under cover pressure.
00:12:20.692 --> 00:12:21.211
We don't.
00:12:21.732 --> 00:12:22.933
And then the clinician,
00:12:22.974 --> 00:12:24.936
we accept the bent treatment plan as
00:12:24.995 --> 00:12:26.576
normal because it's, you know,
00:12:26.636 --> 00:12:27.477
very straightforward.
00:12:27.498 --> 00:12:29.099
That's where the billing code that we
00:12:29.120 --> 00:12:29.679
should have.
00:12:30.400 --> 00:12:30.581
You know,
00:12:30.681 --> 00:12:32.903
every cohort we onboard without teaching
00:12:32.942 --> 00:12:35.245
that separation is another, you know,
00:12:35.932 --> 00:12:38.775
is another class where you're learning the
00:12:38.836 --> 00:12:41.418
portal doesn't have the final word.
00:12:42.477 --> 00:12:43.298
And that's what happens.
00:12:43.339 --> 00:12:44.419
So we didn't sign with a pen.
00:12:44.460 --> 00:12:47.402
We signed with an onboarding calendar and
00:12:47.461 --> 00:12:50.004
silence repeated at scale is signature.
00:12:50.504 --> 00:12:51.884
It's called acceptance.
00:12:52.065 --> 00:12:53.466
It's called learned helplessness.
00:12:54.385 --> 00:12:55.886
what we should be teaching is a
00:12:55.947 --> 00:12:56.788
conversation.
00:12:57.248 --> 00:12:57.989
So people say, well,
00:12:58.048 --> 00:12:59.330
it might take a little longer.
00:12:59.370 --> 00:12:59.649
Okay,
00:12:59.669 --> 00:13:00.951
but if it takes you a little longer,
00:13:00.990 --> 00:13:02.731
your treatment case acceptance can go from
00:13:02.772 --> 00:13:04.513
fifty to seventy to one hundred percent or
00:13:04.572 --> 00:13:05.453
ninety percent.
00:13:07.154 --> 00:13:07.696
And, you know,
00:13:07.796 --> 00:13:09.956
patients generally like listening to their
00:13:09.996 --> 00:13:11.698
doctor, you know, generally.
00:13:13.500 --> 00:13:16.341
And it's why we let an intermediary like
00:13:16.461 --> 00:13:18.703
a fee schedule or an insurance portal get
00:13:18.724 --> 00:13:19.264
in the way.
00:13:19.823 --> 00:13:22.546
And we have to fundamentally reverse that,
00:13:22.566 --> 00:13:23.167
in my opinion.
00:13:23.835 --> 00:13:25.076
right well what i also know about you
00:13:25.135 --> 00:13:26.157
is you don't just sort of drop a
00:13:26.197 --> 00:13:27.738
question and say i guess you'll figure it
00:13:27.817 --> 00:13:29.578
out so you your fix is really three
00:13:29.619 --> 00:13:31.921
questions also in the order the order of
00:13:31.980 --> 00:13:33.642
questions does in fact matter and here's
00:13:33.662 --> 00:13:36.264
your three what does the patient need what
00:13:36.283 --> 00:13:38.926
will coverage support how do i have that
00:13:38.985 --> 00:13:42.349
conversation so why those questions why
00:13:42.369 --> 00:13:44.990
does the order matter so much yeah i
00:13:45.030 --> 00:13:47.173
mean the order is the intervention
00:13:48.102 --> 00:13:48.722
Think about that.
00:13:49.023 --> 00:13:50.802
That's the intervention is those three
00:13:50.822 --> 00:13:51.504
things in order.
00:13:51.864 --> 00:13:53.583
What does the patient actually need?
00:13:54.344 --> 00:13:56.224
Unfiltered clinical judgment before
00:13:56.344 --> 00:13:57.965
anybody opens a benefit portal.
00:13:57.985 --> 00:13:59.605
What do they need?
00:13:59.625 --> 00:14:00.684
That's the whole program.
00:14:01.565 --> 00:14:02.926
Sort of then the second question,
00:14:03.186 --> 00:14:04.686
what will coverage support?
00:14:04.725 --> 00:14:05.966
That's a data point.
00:14:06.306 --> 00:14:07.066
I run a business.
00:14:07.125 --> 00:14:08.846
I don't get to pretend that coverage
00:14:08.886 --> 00:14:09.647
doesn't exist.
00:14:09.726 --> 00:14:10.547
I understand that.
00:14:11.086 --> 00:14:12.947
But a data point is not the answer.
00:14:13.727 --> 00:14:15.607
In most groups trained patients,
00:14:15.990 --> 00:14:18.091
those two questions it really only that
00:14:18.131 --> 00:14:20.774
question only which is how the data point
00:14:20.813 --> 00:14:23.816
got promoted to a ceo right so what
00:14:23.836 --> 00:14:25.256
does a clinician need or what the patient
00:14:25.277 --> 00:14:26.658
need what's what does it covers and that
00:14:26.717 --> 00:14:28.479
is has become the data point but where
00:14:28.499 --> 00:14:30.600
to take number three is the third question
00:14:31.201 --> 00:14:33.283
how do i have this conversation so it
00:14:33.342 --> 00:14:34.524
builds trust
00:14:35.711 --> 00:14:37.471
That's not a clinical skill.
00:14:37.772 --> 00:14:39.273
That's a communication skill.
00:14:39.352 --> 00:14:40.514
It's an empathy skill.
00:14:40.614 --> 00:14:43.096
It's positive psychology in the operatory,
00:14:43.235 --> 00:14:44.296
in dentistry anyhow.
00:14:44.856 --> 00:14:46.717
And it's the delivery mechanism for the
00:14:46.758 --> 00:14:47.278
first two.
00:14:47.778 --> 00:14:50.059
The best clinical judgment in the world
00:14:50.679 --> 00:14:52.341
dies in a bad conversation.
00:14:52.640 --> 00:14:53.322
It just does.
00:14:53.841 --> 00:14:56.024
A dentist who can do all three isn't
00:14:56.163 --> 00:14:57.945
selling, they're treating.
00:14:57.965 --> 00:14:59.566
And that's why I say the order is
00:14:59.605 --> 00:15:00.426
the intervention.
00:15:00.907 --> 00:15:02.587
Patients can feel the difference.
00:15:03.268 --> 00:15:04.469
And so can the clinician,
00:15:04.489 --> 00:15:06.811
which is only half of why the ones
00:15:07.311 --> 00:15:09.832
who really learn this really have such
00:15:09.932 --> 00:15:12.215
high clinical acceptance rate.
00:15:12.235 --> 00:15:12.875
And by the way,
00:15:12.914 --> 00:15:14.976
the higher the clinical acceptance rate,
00:15:14.996 --> 00:15:17.759
the correlation is the proxy efficacy or
00:15:17.778 --> 00:15:19.139
the trust or the thought,
00:15:19.600 --> 00:15:21.601
I have the best provider and a validated
00:15:21.662 --> 00:15:22.903
instrument to patients.
00:15:23.582 --> 00:15:25.325
So patients who get talked to
00:15:26.638 --> 00:15:29.879
as though that was the medicine and the
00:15:29.919 --> 00:15:30.600
intervention,
00:15:30.740 --> 00:15:33.620
as opposed to that's the insurance
00:15:33.682 --> 00:15:37.602
transfer here, really view it as medicine,
00:15:37.663 --> 00:15:39.303
really view it as the intervention.
00:15:39.403 --> 00:15:40.024
It's interesting.
00:15:40.044 --> 00:15:42.865
All right, well, you have to pretend now.
00:15:42.885 --> 00:15:45.868
All right, I'm the CFO.
00:15:45.908 --> 00:15:46.888
Let me see if I got this right.
00:15:47.148 --> 00:15:48.509
You want me to spend more money on
00:15:48.548 --> 00:15:51.149
training and mentorship and case review
00:15:51.190 --> 00:15:53.230
and communication skills before
00:15:53.291 --> 00:15:54.392
productivity shows up.
00:15:55.326 --> 00:15:57.607
How do you show the CFO where I
00:15:57.668 --> 00:16:00.370
get my money back?
00:16:00.429 --> 00:16:02.431
Yeah, those are the right questions.
00:16:04.572 --> 00:16:06.773
And the reality is, you know,
00:16:06.893 --> 00:16:08.293
it's this combination of clinical
00:16:08.333 --> 00:16:10.774
confidence plus communication skills.
00:16:11.514 --> 00:16:12.135
What happens?
00:16:12.456 --> 00:16:13.817
Case acceptance improves.
00:16:14.297 --> 00:16:15.017
That's number one.
00:16:15.317 --> 00:16:17.918
Procedure mixing strengthens, right?
00:16:17.938 --> 00:16:20.000
So more expensive upskilled procedures.
00:16:20.740 --> 00:16:21.620
What decreases?
00:16:21.861 --> 00:16:23.985
Marketing costs per new patient drops
00:16:24.466 --> 00:16:26.207
because patients treated with that kind of
00:16:26.248 --> 00:16:27.370
respect refer.
00:16:27.789 --> 00:16:29.332
And that's why you need this sort of,
00:16:29.352 --> 00:16:30.413
you know, friends,
00:16:30.433 --> 00:16:32.076
family referral statistic.
00:16:32.496 --> 00:16:34.639
That last link is the one CFO is
00:16:34.679 --> 00:16:35.341
under price.
00:16:36.235 --> 00:16:39.817
A referred patient arrives essentially for
00:16:39.878 --> 00:16:41.759
free, no customer acquisition costs,
00:16:42.220 --> 00:16:45.202
trusting you and more so ready to accept
00:16:45.243 --> 00:16:47.205
treatment case and accepting you.
00:16:47.664 --> 00:16:49.647
While marketing, you pay retail for,
00:16:50.147 --> 00:16:50.386
right?
00:16:50.407 --> 00:16:51.227
You call in the air,
00:16:51.288 --> 00:16:53.190
you have lead generation, you have,
00:16:53.250 --> 00:16:54.951
I call those things the leaky bucket.
00:16:55.371 --> 00:16:56.613
You may pay, you know,
00:16:56.633 --> 00:16:57.833
the math runs something like this.
00:16:57.854 --> 00:16:59.655
You may pay eighty one dollars a lead.
00:17:00.712 --> 00:17:02.153
or a hundred and fifty to two hundred
00:17:02.193 --> 00:17:03.294
dollar acquisition cost.
00:17:03.355 --> 00:17:04.935
Are you familiar with Zocdoc and these
00:17:04.955 --> 00:17:05.655
kind of companies?
00:17:05.817 --> 00:17:06.457
Sure.
00:17:06.477 --> 00:17:06.557
Yeah.
00:17:06.576 --> 00:17:06.676
Well,
00:17:06.696 --> 00:17:08.597
those are transactional relationships.
00:17:09.118 --> 00:17:10.740
You pay more for them than you're going
00:17:10.759 --> 00:17:11.799
to get that first visit.
00:17:11.819 --> 00:17:12.280
And guess what?
00:17:12.320 --> 00:17:13.981
You pay whether they show up or not.
00:17:15.063 --> 00:17:16.723
One eight hundred dentists is another one.
00:17:17.344 --> 00:17:19.104
And so all of this,
00:17:20.085 --> 00:17:22.325
you're using your relationships to fuel
00:17:22.464 --> 00:17:24.165
everything from treatment case acceptance,
00:17:24.205 --> 00:17:26.925
better payer mix, to referrals,
00:17:27.266 --> 00:17:28.707
and then marketing savings.
00:17:29.307 --> 00:17:30.467
And the five-year button,
00:17:30.626 --> 00:17:32.086
in five years from now,
00:17:33.047 --> 00:17:35.627
my competitor is still renting patients
00:17:35.667 --> 00:17:38.148
from Google, Jarvis, ZocDoc,
00:17:38.269 --> 00:17:39.269
one eight hundred dentists.
00:17:40.419 --> 00:17:41.378
renting confidence,
00:17:41.419 --> 00:17:43.160
which from whatever office their
00:17:43.200 --> 00:17:45.539
associates are in, paying retail for both.
00:17:46.140 --> 00:17:47.240
And every January,
00:17:47.280 --> 00:17:49.000
the meter resets to zero.
00:17:49.601 --> 00:17:49.861
Now,
00:17:50.121 --> 00:17:52.102
if I own a training pipeline for dentists
00:17:52.122 --> 00:17:54.102
to choose on purpose and a patient base
00:17:54.122 --> 00:17:55.002
that recruits for us,
00:17:55.042 --> 00:17:57.083
that's the difference between compounding
00:17:57.663 --> 00:17:58.222
and rent,
00:17:58.722 --> 00:18:01.884
human capital and expense and marketing
00:18:01.923 --> 00:18:02.743
and lead generation.
00:18:02.763 --> 00:18:03.444
Does that make sense?
00:18:03.565 --> 00:18:04.884
It's a fundamental difference.
00:18:05.298 --> 00:18:05.598
Yeah.
00:18:05.719 --> 00:18:05.939
All right.
00:18:05.959 --> 00:18:06.499
So bottom line,
00:18:06.519 --> 00:18:07.779
the payer isn't going away.
00:18:08.460 --> 00:18:10.799
There are benefits or fee schedules or
00:18:10.839 --> 00:18:11.859
coverage limitations.
00:18:12.661 --> 00:18:13.320
Your argument,
00:18:13.340 --> 00:18:15.760
your article is about who gets the first
00:18:15.861 --> 00:18:18.842
vote, need first, coverage second,
00:18:19.122 --> 00:18:22.583
conversation, then third in that order.
00:18:23.123 --> 00:18:23.522
Because really,
00:18:23.542 --> 00:18:24.502
it sounds like you're saying a treatment
00:18:24.542 --> 00:18:26.084
plan quietly filtered through someone
00:18:26.124 --> 00:18:28.263
else's actuarial model isn't really a
00:18:28.344 --> 00:18:29.084
treatment plan.
00:18:29.523 --> 00:18:30.203
It's surrender.
00:18:30.243 --> 00:18:32.305
It's learned helplessness.
00:18:32.704 --> 00:18:33.565
That's right.
00:18:33.585 --> 00:18:35.526
Part three of your Inside a Platform drops
00:18:35.566 --> 00:18:37.467
next week on the operator on Substack.
00:18:38.366 --> 00:18:40.647
And if you're thinking about these
00:18:40.688 --> 00:18:41.608
questions today,
00:18:41.669 --> 00:18:43.388
make sure you stick around for the next
00:18:43.528 --> 00:18:43.628
one.
00:18:44.089 --> 00:18:45.150
Until then, keep operating.
00:00:05.742 --> 00:00:06.062
All right,
00:00:06.081 --> 00:00:08.602
we spend years training clinicians to make
00:00:08.823 --> 00:00:10.804
good clinical decisions.
00:00:11.365 --> 00:00:13.404
Then they get into practice and another
00:00:13.445 --> 00:00:14.566
voice enters the room.
00:00:15.486 --> 00:00:16.387
What will insurance cover?
00:00:16.946 --> 00:00:17.907
And somewhere along the way,
00:00:17.926 --> 00:00:19.667
that question can start getting asked
00:00:20.169 --> 00:00:20.849
before,
00:00:21.329 --> 00:00:23.089
what does this patient actually need?
00:00:23.890 --> 00:00:26.310
Larry's latest article said that this
00:00:26.370 --> 00:00:27.471
isn't just a payer problem.
00:00:28.111 --> 00:00:30.310
Operators maybe have their hands dirty.
00:00:30.350 --> 00:00:31.532
Maybe they helped build it.
00:00:32.131 --> 00:00:34.432
So let's start by asking this.
00:00:34.771 --> 00:00:36.332
Larry, you start by saying, you know,
00:00:36.393 --> 00:00:37.893
new clinicians are arriving less
00:00:37.953 --> 00:00:39.512
clinically ready than they used to.
00:00:39.573 --> 00:00:40.853
You're careful to say it's not an
00:00:40.893 --> 00:00:43.014
indictment on dental education.
00:00:43.554 --> 00:00:45.393
So then what's sort of changed?
00:00:46.935 --> 00:00:47.914
Yeah, I think, you know,
00:00:48.829 --> 00:00:49.029
Jimmy,
00:00:49.069 --> 00:00:51.011
this is a little bit of a hangover
00:00:51.192 --> 00:00:53.353
from COVID or that actually occurred
00:00:53.393 --> 00:00:54.274
during COVID,
00:00:54.956 --> 00:00:56.938
but fundamentally two things changed and
00:00:56.978 --> 00:00:58.799
only really one of them ever gets talked
00:00:58.820 --> 00:00:59.140
about.
00:01:00.140 --> 00:01:01.682
The structure changed, you know,
00:01:01.762 --> 00:01:04.265
fewer patient volume hours,
00:01:05.117 --> 00:01:06.957
were necessary to graduate.
00:01:06.998 --> 00:01:08.697
So that means you get less procedural
00:01:08.718 --> 00:01:11.680
diversity and you get maybe a little bit
00:01:11.739 --> 00:01:14.421
of earlier specialization is the other
00:01:14.460 --> 00:01:14.941
factor.
00:01:15.561 --> 00:01:17.361
So less reps effectively.
00:01:17.921 --> 00:01:18.561
So they come out,
00:01:18.862 --> 00:01:20.503
the new grad and this traverses
00:01:20.563 --> 00:01:21.144
everything, right?
00:01:21.183 --> 00:01:23.063
They come out technically capable,
00:01:23.444 --> 00:01:24.805
but short on repetition.
00:01:25.685 --> 00:01:27.665
And when you have short on repetition,
00:01:27.706 --> 00:01:29.106
you have short on confidence.
00:01:29.971 --> 00:01:31.653
And really confidence you can only get
00:01:31.694 --> 00:01:32.355
through volume.
00:01:32.715 --> 00:01:33.756
So it becomes a cycle.
00:01:34.537 --> 00:01:37.079
So you can't blame the student.
00:01:37.099 --> 00:01:38.441
Blaming the student is like blaming the
00:01:38.480 --> 00:01:40.423
teenager, you know,
00:01:40.442 --> 00:01:42.105
for being a shaky parallel parker.
00:01:42.144 --> 00:01:44.147
If you had a parallel park when you
00:01:44.427 --> 00:01:45.447
were driving, right?
00:01:45.849 --> 00:01:45.929
Yeah.
00:01:46.228 --> 00:01:48.331
The second thing that changed is nothing.
00:01:48.352 --> 00:01:49.253
And that's the problem.
00:01:49.313 --> 00:01:50.194
We didn't change.
00:01:50.234 --> 00:01:52.457
We still hire like it's nineteen ninety
00:01:52.498 --> 00:01:52.918
five.
00:01:52.957 --> 00:01:53.218
Right.
00:01:53.299 --> 00:01:53.918
Week one.
00:01:53.959 --> 00:01:54.840
Here's your schedule.
00:01:55.240 --> 00:01:56.643
Here's the production target.
00:01:57.745 --> 00:01:59.686
We built our expectations around a
00:01:59.746 --> 00:02:00.929
graduate graduation.
00:02:01.149 --> 00:02:03.391
effectively stopped existing years ago.
00:02:03.430 --> 00:02:04.972
And so, as I said,
00:02:05.033 --> 00:02:07.094
I've seen the same thing happen in
00:02:07.234 --> 00:02:08.836
physical therapy for four years.
00:02:08.895 --> 00:02:11.919
Every clinical profession that compresses
00:02:11.959 --> 00:02:14.662
hands-on hours produces the same graduate,
00:02:15.181 --> 00:02:18.085
smart, credentialed, but under repetition,
00:02:18.525 --> 00:02:20.948
therefore lack of clinical confidence.
00:02:21.527 --> 00:02:23.050
Dentistry isn't anything special.
00:02:23.129 --> 00:02:24.950
It's just sort of late to admitting it.
00:02:26.848 --> 00:02:28.469
Yeah, yeah.
00:02:28.610 --> 00:02:29.752
You've said these clinicians enter
00:02:29.792 --> 00:02:32.133
organizations that want them to also do
00:02:32.174 --> 00:02:34.697
this, be productive quickly.
00:02:34.836 --> 00:02:36.538
This feels like putting dysfunction on
00:02:36.699 --> 00:02:37.280
instability.
00:02:37.901 --> 00:02:39.421
How are most platforms trying to close
00:02:39.443 --> 00:02:39.983
that gap?
00:02:40.022 --> 00:02:41.324
Like, you know,
00:02:41.344 --> 00:02:42.825
what's wrong besides the obvious on that
00:02:42.866 --> 00:02:43.266
approach?
00:02:43.860 --> 00:02:44.020
Yeah,
00:02:44.039 --> 00:02:46.522
so the implications of high clinical
00:02:46.562 --> 00:02:49.064
shortages, less therapists, less dentists,
00:02:49.126 --> 00:02:49.985
less doctors,
00:02:50.967 --> 00:02:52.829
is that you become very efficient in
00:02:52.949 --> 00:02:53.370
onboarding.
00:02:53.389 --> 00:02:55.051
You give them a checklist and a production
00:02:55.092 --> 00:02:55.491
target.
00:02:55.812 --> 00:02:57.454
That's sort of the industry's answer.
00:02:58.055 --> 00:03:00.516
And I wish I was exaggerating.
00:03:02.158 --> 00:03:03.120
You get orientation,
00:03:03.139 --> 00:03:04.602
maybe a tour of the break room,
00:03:04.861 --> 00:03:06.082
maybe some shadowing,
00:03:06.122 --> 00:03:08.064
but the idea is go produce.
00:03:08.105 --> 00:03:09.026
You've got a salary.
00:03:09.046 --> 00:03:10.807
We're paying you higher than we ever have.
00:03:12.129 --> 00:03:12.751
Go produce.
00:03:12.790 --> 00:03:14.812
That's not development.
00:03:14.832 --> 00:03:17.155
That's hope with a paperwork, right?
00:03:17.194 --> 00:03:19.037
What's wrong with it is that it treats
00:03:19.116 --> 00:03:22.020
clinical readiness, which is a problem.
00:03:22.080 --> 00:03:24.143
It treats it as a scheduling problem.
00:03:25.050 --> 00:03:26.872
And so the dental company of the future,
00:03:26.931 --> 00:03:28.572
the physical therapy company of the future
00:03:28.632 --> 00:03:30.932
builds an actual infrastructure.
00:03:31.633 --> 00:03:32.372
Mentorship,
00:03:32.653 --> 00:03:35.974
simulation was real common in dentistry
00:03:36.014 --> 00:03:37.794
now, structured case review,
00:03:37.895 --> 00:03:39.195
deliberate practice.
00:03:39.716 --> 00:03:40.795
That's the big buzzword.
00:03:40.855 --> 00:03:41.256
And yes,
00:03:41.956 --> 00:03:44.457
overhead does rise before productivity
00:03:44.478 --> 00:03:44.957
shows up.
00:03:44.978 --> 00:03:48.338
So you have to think of human capital
00:03:48.519 --> 00:03:49.459
as an investment,
00:03:49.498 --> 00:03:51.379
like you were buying a piece of equipment
00:03:51.460 --> 00:03:53.120
or a modality in physical therapy
00:03:53.180 --> 00:03:53.580
language.
00:03:55.324 --> 00:03:57.686
you know, I won't pretend it's otherwise.
00:03:57.725 --> 00:04:00.687
And so human capital is an investment and
00:04:00.866 --> 00:04:02.206
it's cap X.
00:04:02.986 --> 00:04:04.687
And you have to understand that you're
00:04:04.728 --> 00:04:06.548
going to get less productivity and you
00:04:06.568 --> 00:04:07.929
have to model it that way.
00:04:08.468 --> 00:04:10.469
But the multiplier on the other side of
00:04:10.509 --> 00:04:12.090
this retention engagement,
00:04:12.629 --> 00:04:14.950
better procedure mix, better referrals,
00:04:14.971 --> 00:04:16.791
you know, that's unambiguous.
00:04:16.851 --> 00:04:17.872
It's very objective.
00:04:18.172 --> 00:04:20.132
And the benefit is to the company
00:04:20.173 --> 00:04:21.112
downstream.
00:04:21.192 --> 00:04:21.353
Yeah.
00:04:21.911 --> 00:04:22.091
Yeah.
00:04:22.151 --> 00:04:23.632
Well, you've done something about this.
00:04:23.692 --> 00:04:24.252
At DCA,
00:04:24.273 --> 00:04:26.355
you've actually built something called
00:04:26.435 --> 00:04:26.855
Ascend,
00:04:26.894 --> 00:04:28.875
which you described as almost like a
00:04:29.196 --> 00:04:31.978
residency for general dentists,
00:04:31.997 --> 00:04:33.178
for general practitioners.
00:04:33.519 --> 00:04:35.180
What are you trying to create that maybe
00:04:35.220 --> 00:04:38.262
an ordinary onboarding or mentorship
00:04:38.322 --> 00:04:38.661
doesn't?
00:04:39.360 --> 00:04:39.600
Yeah.
00:04:39.641 --> 00:04:42.043
So I did this same playbook in physical
00:04:42.083 --> 00:04:43.564
therapy where we had the initial
00:04:43.625 --> 00:04:45.086
certification programs.
00:04:45.646 --> 00:04:47.608
These are best thought of as not short
00:04:47.648 --> 00:04:49.769
term weekend courses, but longer term.
00:04:50.230 --> 00:04:51.891
Then those became residencies.
00:04:51.932 --> 00:04:53.273
Physical therapy became accredited
00:04:53.333 --> 00:04:53.913
residencies.
00:04:53.994 --> 00:04:55.995
We have those in dentistry as well,
00:04:56.596 --> 00:04:57.976
but they're a lot more profound and a
00:04:58.016 --> 00:04:59.639
lot more accreditation risk.
00:05:00.259 --> 00:05:02.141
And so what we do now is develop
00:05:02.161 --> 00:05:02.800
a curriculum.
00:05:03.903 --> 00:05:05.105
And if you think about it,
00:05:05.245 --> 00:05:08.408
ordinary mentorship depends on entirely
00:05:08.468 --> 00:05:10.970
where the dentist or the therapist lands,
00:05:11.009 --> 00:05:11.189
right?
00:05:11.209 --> 00:05:13.492
Maybe there's a great senior therapist or
00:05:13.531 --> 00:05:14.172
doctor there.
00:05:14.192 --> 00:05:15.634
And if that happens, you flourish.
00:05:16.394 --> 00:05:17.355
So what Ascend is,
00:05:17.415 --> 00:05:19.375
is really a certification pathway.
00:05:19.516 --> 00:05:21.358
It's advanced training for a general
00:05:21.418 --> 00:05:22.019
dentist
00:05:22.718 --> 00:05:24.920
to get upskilled in endodontics,
00:05:25.060 --> 00:05:26.620
orthodontics, restorative.
00:05:28.401 --> 00:05:30.923
Medicine decided a century ago that a
00:05:31.004 --> 00:05:33.045
residency is how you turn a graduate into
00:05:33.084 --> 00:05:33.725
a physician.
00:05:35.185 --> 00:05:37.406
And dentistry sort of is winging it,
00:05:37.865 --> 00:05:39.805
for lack of a better term.
00:05:41.127 --> 00:05:42.026
It's interesting.
00:05:43.367 --> 00:05:45.367
The Army taught me this well before
00:05:45.427 --> 00:05:46.228
dentistry did.
00:05:46.327 --> 00:05:48.408
Nobody in the military hands you a mission
00:05:48.427 --> 00:05:50.309
without a training pipeline behind it.
00:05:51.009 --> 00:05:53.108
But in dentistry, we have a mission.
00:05:53.129 --> 00:05:56.850
But we basically say to the dentist,
00:05:56.970 --> 00:05:57.750
figure it out.
00:05:58.011 --> 00:06:01.190
And getting upskilled is expensive.
00:06:01.651 --> 00:06:02.992
And you've already got somebody who's got
00:06:03.012 --> 00:06:03.971
a lot of student debt.
00:06:05.216 --> 00:06:06.857
The good news is like in a general
00:06:07.076 --> 00:06:08.817
GP, a general practitioner in dentistry,
00:06:08.836 --> 00:06:11.017
a general dentist has a very liberal
00:06:11.057 --> 00:06:11.937
practice act.
00:06:13.298 --> 00:06:13.918
In healthcare,
00:06:13.978 --> 00:06:16.019
I can never get my primary care docs
00:06:16.040 --> 00:06:18.240
to deliver a baby or to do orthopedic
00:06:18.281 --> 00:06:18.740
surgery.
00:06:19.221 --> 00:06:20.300
But in dentistry,
00:06:20.641 --> 00:06:22.622
a general dentist can do orthodontics,
00:06:22.742 --> 00:06:25.002
oral surgery, endodontics, periodontics,
00:06:25.543 --> 00:06:27.303
and can do it rather well.
00:06:27.463 --> 00:06:27.684
Now,
00:06:27.884 --> 00:06:30.185
there's a defined line of what they can't
00:06:30.225 --> 00:06:30.345
do.
00:06:31.084 --> 00:06:32.185
But they can be upskilled.
00:06:32.646 --> 00:06:33.846
And so in order to do that, though,
00:06:33.865 --> 00:06:34.725
you have to have training.
00:06:34.766 --> 00:06:35.365
What is training?
00:06:35.726 --> 00:06:36.807
Training takes investment,
00:06:36.867 --> 00:06:38.487
investment in human capital.
00:06:39.028 --> 00:06:39.348
Again,
00:06:39.408 --> 00:06:41.228
we think of de novos and equipment and
00:06:41.288 --> 00:06:42.528
space and build outs.
00:06:43.009 --> 00:06:44.528
We have to start thinking of our human
00:06:44.569 --> 00:06:46.990
beings under those same investment thesis.
00:06:47.644 --> 00:06:48.084
Yeah.
00:06:48.444 --> 00:06:48.584
Well,
00:06:48.605 --> 00:06:49.886
here comes a sentence that brings somebody
00:06:49.925 --> 00:06:50.826
else back into the room.
00:06:51.206 --> 00:06:53.146
We're training a clinician to let a payer
00:06:53.187 --> 00:06:54.987
make clinical decisions.
00:06:55.187 --> 00:06:55.908
That's serious.
00:06:55.928 --> 00:06:57.569
That's some hot take, right?
00:06:57.649 --> 00:06:59.389
So how does a clinician get trained to
00:06:59.430 --> 00:07:02.071
do that without anyone ever explicitly
00:07:02.791 --> 00:07:04.052
teaching them to do that?
00:07:04.632 --> 00:07:04.853
Yeah,
00:07:04.913 --> 00:07:06.752
so all these things sort of happen by
00:07:06.812 --> 00:07:07.593
default.
00:07:07.853 --> 00:07:09.834
We send a default to what the payer
00:07:09.875 --> 00:07:10.175
does.
00:07:11.805 --> 00:07:13.648
But if you think about it in dentistry,
00:07:13.668 --> 00:07:15.949
it's a little bit worse because the
00:07:16.009 --> 00:07:18.872
dentist will say to a patient, OK,
00:07:18.913 --> 00:07:21.516
go now talk to our treatment coordinator
00:07:21.976 --> 00:07:23.678
who will talk to you about our insurance.
00:07:23.699 --> 00:07:27.041
So we outsource the decision making to
00:07:27.101 --> 00:07:29.043
somebody who's not even a clinician.
00:07:30.125 --> 00:07:32.127
And that's just absolutely wrong,
00:07:32.348 --> 00:07:32.608
you know.
00:07:33.975 --> 00:07:35.757
A plan gets, think about it,
00:07:35.797 --> 00:07:37.877
a plan gets denied in dental or
00:07:37.916 --> 00:07:38.478
healthcare.
00:07:39.137 --> 00:07:40.617
A code gets downgraded.
00:07:41.317 --> 00:07:43.119
Something happens with a write-off.
00:07:43.978 --> 00:07:46.959
And all we tend to do then is
00:07:47.000 --> 00:07:49.620
just kind of default and we train this
00:07:49.740 --> 00:07:51.541
into our system rather than just
00:07:51.581 --> 00:07:54.362
fundamentally understanding that the
00:07:54.403 --> 00:07:56.202
clinician should be having the discussion
00:07:56.242 --> 00:07:57.084
with the patient.
00:07:57.264 --> 00:07:59.384
The payer should be secondary to all that.
00:08:00.925 --> 00:08:02.526
I refer to all this as learned
00:08:02.605 --> 00:08:03.346
helplessness.
00:08:04.420 --> 00:08:06.141
As you remember,
00:08:06.201 --> 00:08:08.983
I've got a degree and master's of applied
00:08:09.043 --> 00:08:10.324
positive psychology from University of
00:08:10.363 --> 00:08:12.505
Pennsylvania where Marty Seligman,
00:08:12.526 --> 00:08:15.507
you know, Angela Duckworth,
00:08:16.228 --> 00:08:18.069
all those luminaries teach.
00:08:18.709 --> 00:08:20.511
And Marty Seligman really was the
00:08:20.571 --> 00:08:22.812
researcher who in the nineteen sixties,
00:08:22.892 --> 00:08:24.874
well before there was optimism,
00:08:25.495 --> 00:08:27.475
defined learn helplessness,
00:08:27.596 --> 00:08:29.317
which is the idea that no matter what
00:08:29.396 --> 00:08:31.238
I do, what I respond to,
00:08:31.538 --> 00:08:33.059
it doesn't impact the outcome.
00:08:34.251 --> 00:08:37.094
And when you can't impact the outcome,
00:08:37.514 --> 00:08:38.774
you learn to be helpless.
00:08:39.434 --> 00:08:41.235
And that's what's effectively happened in
00:08:41.296 --> 00:08:41.755
healthcare.
00:08:41.775 --> 00:08:44.457
A clinician whose judgment keeps getting
00:08:44.638 --> 00:08:46.578
overruled by a portal,
00:08:47.259 --> 00:08:48.340
an insurance portal,
00:08:48.379 --> 00:08:50.441
stop exercising the judgment.
00:08:50.461 --> 00:08:53.182
And so the portal doesn't have to win
00:08:53.201 --> 00:08:54.082
the argument anymore.
00:08:54.123 --> 00:08:55.403
There is no argument.
00:08:56.063 --> 00:08:56.845
In physical therapy,
00:08:56.884 --> 00:08:58.265
this happens a bit as well.
00:08:58.326 --> 00:09:00.648
It's just that our codes are more
00:09:00.727 --> 00:09:01.508
scrunched in.
00:09:02.269 --> 00:09:02.928
They're fewer.
00:09:03.269 --> 00:09:04.870
They're not as diverse and there's not as
00:09:04.931 --> 00:09:08.854
many procedural-driven expensive codes.
00:09:09.875 --> 00:09:11.355
And what happens in dentistry, again,
00:09:11.395 --> 00:09:13.076
is we just sort of outsource all this
00:09:13.116 --> 00:09:15.759
because we learn we shouldn't be doing
00:09:15.779 --> 00:09:15.899
that.
00:09:15.940 --> 00:09:18.000
The reality is those conversations should
00:09:18.140 --> 00:09:20.243
absolutely be happening between the
00:09:20.283 --> 00:09:22.164
clinician and the patient.
00:09:23.195 --> 00:09:26.376
You painted this recognizable scene that I
00:09:26.437 --> 00:09:28.138
think many people in healthcare have
00:09:28.238 --> 00:09:28.859
walked through,
00:09:28.918 --> 00:09:29.940
and maybe you never named it,
00:09:29.960 --> 00:09:32.500
but the clinician knows what the patient
00:09:32.541 --> 00:09:32.922
needs.
00:09:33.501 --> 00:09:34.942
They then open the benefits portal,
00:09:35.023 --> 00:09:35.903
and then all of a sudden,
00:09:35.923 --> 00:09:37.004
without anybody telling them to,
00:09:37.043 --> 00:09:39.025
the treatment plan then bends.
00:09:39.346 --> 00:09:40.726
It shifts.
00:09:40.746 --> 00:09:42.347
What's sort of happening in that moment?
00:09:42.368 --> 00:09:43.447
You've touched on it a little bit,
00:09:43.489 --> 00:09:44.568
but what's going on there?
00:09:45.190 --> 00:09:46.730
Yeah, so the judgment comes first,
00:09:46.770 --> 00:09:47.850
and it's very real, right?
00:09:47.890 --> 00:09:49.192
They see the right answer.
00:09:49.812 --> 00:09:51.774
Years of training are pointing at it.
00:09:52.198 --> 00:09:53.744
Then the portal opens up and the plan
00:09:53.825 --> 00:09:55.671
reshapes itself around the coverage.
00:09:56.481 --> 00:09:57.602
And what does it cover and what does
00:09:57.643 --> 00:09:58.283
it not cover?
00:09:58.342 --> 00:09:59.283
Nobody orders it.
00:09:59.783 --> 00:10:01.445
And here's what makes it dangerous from
00:10:01.465 --> 00:10:02.005
the inside.
00:10:02.046 --> 00:10:03.947
It never feels like surrender.
00:10:03.966 --> 00:10:05.408
It feels like being realistic,
00:10:05.447 --> 00:10:07.229
being practical, being a team player,
00:10:07.668 --> 00:10:09.509
trying to be patient centric,
00:10:09.549 --> 00:10:10.990
understanding what they have and what they
00:10:11.030 --> 00:10:11.292
don't.
00:10:12.011 --> 00:10:12.652
Well, in dental,
00:10:12.792 --> 00:10:14.113
there's not true underwriting and
00:10:14.173 --> 00:10:14.793
insurance.
00:10:15.533 --> 00:10:20.096
And really the conversation has to sort of
00:10:20.717 --> 00:10:22.219
happen between the patient and the
00:10:23.099 --> 00:10:23.740
clinician
00:10:24.767 --> 00:10:27.128
and then you know secondarily to that
00:10:27.227 --> 00:10:28.448
whatever insurance covers whatever
00:10:28.489 --> 00:10:30.250
insurance covers right but it's not just
00:10:30.289 --> 00:10:33.890
generally how it works um and so you
00:10:33.910 --> 00:10:35.692
know no dentist in america has ever
00:10:35.751 --> 00:10:38.253
written surrender to the fee schedule in a
00:10:38.312 --> 00:10:40.793
note the chart says the patient elected
00:10:40.833 --> 00:10:43.655
alternative treatment the language is the
00:10:43.716 --> 00:10:46.037
thing that that that launders the moment
00:10:46.860 --> 00:10:48.600
Now there's a data point in dentistry
00:10:48.640 --> 00:10:50.702
called treatment case acceptance.
00:10:51.143 --> 00:10:54.205
That's the number of patients who accept
00:10:54.446 --> 00:10:56.527
what the treatment case is supposed to do.
00:10:57.488 --> 00:10:58.568
Believe it or not, Jimmy,
00:10:58.589 --> 00:11:00.629
that number hovers between fifty and
00:11:00.669 --> 00:11:02.772
seventy five percent.
00:11:02.792 --> 00:11:04.952
The reason it happens that way is because
00:11:04.993 --> 00:11:06.835
of learned helplessness, in my opinion.
00:11:07.559 --> 00:11:10.701
We never really have the clinician have a
00:11:10.760 --> 00:11:11.701
conversation.
00:11:11.881 --> 00:11:13.341
It goes and it gets outsourced.
00:11:13.682 --> 00:11:15.582
When that conversation gets outsourced,
00:11:16.263 --> 00:11:17.884
that percentage doesn't go up,
00:11:17.923 --> 00:11:19.823
it goes down in my view.
00:11:19.903 --> 00:11:19.984
Now,
00:11:20.024 --> 00:11:21.144
there are a lot of practices that would
00:11:21.184 --> 00:11:21.684
disagree.
00:11:21.705 --> 00:11:22.004
They say,
00:11:22.044 --> 00:11:23.846
I don't want the conversation between the
00:11:23.885 --> 00:11:24.926
dentist and the patient,
00:11:24.946 --> 00:11:26.366
but I don't see it that way because
00:11:26.407 --> 00:11:28.807
I think these are clinical issues and not
00:11:28.868 --> 00:11:29.687
insurance issues.
00:11:30.207 --> 00:11:31.009
Yeah.
00:11:31.048 --> 00:11:31.168
Well,
00:11:31.188 --> 00:11:32.208
from what I know about you is you
00:11:32.229 --> 00:11:33.950
try to not make anything a blame game.
00:11:33.990 --> 00:11:35.270
This is where I think in your article,
00:11:35.331 --> 00:11:37.292
you turn sort of the responsibility or the
00:11:37.412 --> 00:11:39.673
accusation towards ourselves, right?
00:11:39.693 --> 00:11:40.835
This is the only thing we can control.
00:11:40.855 --> 00:11:41.875
You're talking about learned helplessness.
00:11:41.894 --> 00:11:43.355
Well, what can we control?
00:11:43.436 --> 00:11:44.616
In the article, you said, well, listen,
00:11:45.136 --> 00:11:46.677
the operators, you signed off on it.
00:11:48.038 --> 00:11:49.240
Okay, where did we sign?
00:11:49.259 --> 00:11:51.620
So that's probably the big question.
00:11:52.221 --> 00:11:52.522
You know,
00:11:52.881 --> 00:11:54.462
where did we sign on for this?
00:11:54.582 --> 00:11:54.962
When?
00:11:55.202 --> 00:11:55.964
How did that happen?
00:11:58.313 --> 00:12:00.937
Yeah, I would say it's how we train.
00:12:00.957 --> 00:12:02.379
I mean, that's the signature.
00:12:03.280 --> 00:12:06.684
No operator ever wrote a memo handing the
00:12:06.745 --> 00:12:07.846
payer the final word.
00:12:08.567 --> 00:12:10.009
We do something a little bit quieter.
00:12:10.682 --> 00:12:10.842
You know,
00:12:10.863 --> 00:12:12.784
we built a development program to teach
00:12:12.845 --> 00:12:14.626
everything except judgment under coverage
00:12:14.667 --> 00:12:15.967
pressure, right?
00:12:16.048 --> 00:12:16.567
Think about it.
00:12:16.707 --> 00:12:19.291
We should be teaching clinicians judgment
00:12:19.431 --> 00:12:20.652
under cover pressure.
00:12:20.692 --> 00:12:21.211
We don't.
00:12:21.732 --> 00:12:22.933
And then the clinician,
00:12:22.974 --> 00:12:24.936
we accept the bent treatment plan as
00:12:24.995 --> 00:12:26.576
normal because it's, you know,
00:12:26.636 --> 00:12:27.477
very straightforward.
00:12:27.498 --> 00:12:29.099
That's where the billing code that we
00:12:29.120 --> 00:12:29.679
should have.
00:12:30.400 --> 00:12:30.581
You know,
00:12:30.681 --> 00:12:32.903
every cohort we onboard without teaching
00:12:32.942 --> 00:12:35.245
that separation is another, you know,
00:12:35.932 --> 00:12:38.775
is another class where you're learning the
00:12:38.836 --> 00:12:41.418
portal doesn't have the final word.
00:12:42.477 --> 00:12:43.298
And that's what happens.
00:12:43.339 --> 00:12:44.419
So we didn't sign with a pen.
00:12:44.460 --> 00:12:47.402
We signed with an onboarding calendar and
00:12:47.461 --> 00:12:50.004
silence repeated at scale is signature.
00:12:50.504 --> 00:12:51.884
It's called acceptance.
00:12:52.065 --> 00:12:53.466
It's called learned helplessness.
00:12:54.385 --> 00:12:55.886
what we should be teaching is a
00:12:55.947 --> 00:12:56.788
conversation.
00:12:57.248 --> 00:12:57.989
So people say, well,
00:12:58.048 --> 00:12:59.330
it might take a little longer.
00:12:59.370 --> 00:12:59.649
Okay,
00:12:59.669 --> 00:13:00.951
but if it takes you a little longer,
00:13:00.990 --> 00:13:02.731
your treatment case acceptance can go from
00:13:02.772 --> 00:13:04.513
fifty to seventy to one hundred percent or
00:13:04.572 --> 00:13:05.453
ninety percent.
00:13:07.154 --> 00:13:07.696
And, you know,
00:13:07.796 --> 00:13:09.956
patients generally like listening to their
00:13:09.996 --> 00:13:11.698
doctor, you know, generally.
00:13:13.500 --> 00:13:16.341
And it's why we let an intermediary like
00:13:16.461 --> 00:13:18.703
a fee schedule or an insurance portal get
00:13:18.724 --> 00:13:19.264
in the way.
00:13:19.823 --> 00:13:22.546
And we have to fundamentally reverse that,
00:13:22.566 --> 00:13:23.167
in my opinion.
00:13:23.835 --> 00:13:25.076
right well what i also know about you
00:13:25.135 --> 00:13:26.157
is you don't just sort of drop a
00:13:26.197 --> 00:13:27.738
question and say i guess you'll figure it
00:13:27.817 --> 00:13:29.578
out so you your fix is really three
00:13:29.619 --> 00:13:31.921
questions also in the order the order of
00:13:31.980 --> 00:13:33.642
questions does in fact matter and here's
00:13:33.662 --> 00:13:36.264
your three what does the patient need what
00:13:36.283 --> 00:13:38.926
will coverage support how do i have that
00:13:38.985 --> 00:13:42.349
conversation so why those questions why
00:13:42.369 --> 00:13:44.990
does the order matter so much yeah i
00:13:45.030 --> 00:13:47.173
mean the order is the intervention
00:13:48.102 --> 00:13:48.722
Think about that.
00:13:49.023 --> 00:13:50.802
That's the intervention is those three
00:13:50.822 --> 00:13:51.504
things in order.
00:13:51.864 --> 00:13:53.583
What does the patient actually need?
00:13:54.344 --> 00:13:56.224
Unfiltered clinical judgment before
00:13:56.344 --> 00:13:57.965
anybody opens a benefit portal.
00:13:57.985 --> 00:13:59.605
What do they need?
00:13:59.625 --> 00:14:00.684
That's the whole program.
00:14:01.565 --> 00:14:02.926
Sort of then the second question,
00:14:03.186 --> 00:14:04.686
what will coverage support?
00:14:04.725 --> 00:14:05.966
That's a data point.
00:14:06.306 --> 00:14:07.066
I run a business.
00:14:07.125 --> 00:14:08.846
I don't get to pretend that coverage
00:14:08.886 --> 00:14:09.647
doesn't exist.
00:14:09.726 --> 00:14:10.547
I understand that.
00:14:11.086 --> 00:14:12.947
But a data point is not the answer.
00:14:13.727 --> 00:14:15.607
In most groups trained patients,
00:14:15.990 --> 00:14:18.091
those two questions it really only that
00:14:18.131 --> 00:14:20.774
question only which is how the data point
00:14:20.813 --> 00:14:23.816
got promoted to a ceo right so what
00:14:23.836 --> 00:14:25.256
does a clinician need or what the patient
00:14:25.277 --> 00:14:26.658
need what's what does it covers and that
00:14:26.717 --> 00:14:28.479
is has become the data point but where
00:14:28.499 --> 00:14:30.600
to take number three is the third question
00:14:31.201 --> 00:14:33.283
how do i have this conversation so it
00:14:33.342 --> 00:14:34.524
builds trust
00:14:35.711 --> 00:14:37.471
That's not a clinical skill.
00:14:37.772 --> 00:14:39.273
That's a communication skill.
00:14:39.352 --> 00:14:40.514
It's an empathy skill.
00:14:40.614 --> 00:14:43.096
It's positive psychology in the operatory,
00:14:43.235 --> 00:14:44.296
in dentistry anyhow.
00:14:44.856 --> 00:14:46.717
And it's the delivery mechanism for the
00:14:46.758 --> 00:14:47.278
first two.
00:14:47.778 --> 00:14:50.059
The best clinical judgment in the world
00:14:50.679 --> 00:14:52.341
dies in a bad conversation.
00:14:52.640 --> 00:14:53.322
It just does.
00:14:53.841 --> 00:14:56.024
A dentist who can do all three isn't
00:14:56.163 --> 00:14:57.945
selling, they're treating.
00:14:57.965 --> 00:14:59.566
And that's why I say the order is
00:14:59.605 --> 00:15:00.426
the intervention.
00:15:00.907 --> 00:15:02.587
Patients can feel the difference.
00:15:03.268 --> 00:15:04.469
And so can the clinician,
00:15:04.489 --> 00:15:06.811
which is only half of why the ones
00:15:07.311 --> 00:15:09.832
who really learn this really have such
00:15:09.932 --> 00:15:12.215
high clinical acceptance rate.
00:15:12.235 --> 00:15:12.875
And by the way,
00:15:12.914 --> 00:15:14.976
the higher the clinical acceptance rate,
00:15:14.996 --> 00:15:17.759
the correlation is the proxy efficacy or
00:15:17.778 --> 00:15:19.139
the trust or the thought,
00:15:19.600 --> 00:15:21.601
I have the best provider and a validated
00:15:21.662 --> 00:15:22.903
instrument to patients.
00:15:23.582 --> 00:15:25.325
So patients who get talked to
00:15:26.638 --> 00:15:29.879
as though that was the medicine and the
00:15:29.919 --> 00:15:30.600
intervention,
00:15:30.740 --> 00:15:33.620
as opposed to that's the insurance
00:15:33.682 --> 00:15:37.602
transfer here, really view it as medicine,
00:15:37.663 --> 00:15:39.303
really view it as the intervention.
00:15:39.403 --> 00:15:40.024
It's interesting.
00:15:40.044 --> 00:15:42.865
All right, well, you have to pretend now.
00:15:42.885 --> 00:15:45.868
All right, I'm the CFO.
00:15:45.908 --> 00:15:46.888
Let me see if I got this right.
00:15:47.148 --> 00:15:48.509
You want me to spend more money on
00:15:48.548 --> 00:15:51.149
training and mentorship and case review
00:15:51.190 --> 00:15:53.230
and communication skills before
00:15:53.291 --> 00:15:54.392
productivity shows up.
00:15:55.326 --> 00:15:57.607
How do you show the CFO where I
00:15:57.668 --> 00:16:00.370
get my money back?
00:16:00.429 --> 00:16:02.431
Yeah, those are the right questions.
00:16:04.572 --> 00:16:06.773
And the reality is, you know,
00:16:06.893 --> 00:16:08.293
it's this combination of clinical
00:16:08.333 --> 00:16:10.774
confidence plus communication skills.
00:16:11.514 --> 00:16:12.135
What happens?
00:16:12.456 --> 00:16:13.817
Case acceptance improves.
00:16:14.297 --> 00:16:15.017
That's number one.
00:16:15.317 --> 00:16:17.918
Procedure mixing strengthens, right?
00:16:17.938 --> 00:16:20.000
So more expensive upskilled procedures.
00:16:20.740 --> 00:16:21.620
What decreases?
00:16:21.861 --> 00:16:23.985
Marketing costs per new patient drops
00:16:24.466 --> 00:16:26.207
because patients treated with that kind of
00:16:26.248 --> 00:16:27.370
respect refer.
00:16:27.789 --> 00:16:29.332
And that's why you need this sort of,
00:16:29.352 --> 00:16:30.413
you know, friends,
00:16:30.433 --> 00:16:32.076
family referral statistic.
00:16:32.496 --> 00:16:34.639
That last link is the one CFO is
00:16:34.679 --> 00:16:35.341
under price.
00:16:36.235 --> 00:16:39.817
A referred patient arrives essentially for
00:16:39.878 --> 00:16:41.759
free, no customer acquisition costs,
00:16:42.220 --> 00:16:45.202
trusting you and more so ready to accept
00:16:45.243 --> 00:16:47.205
treatment case and accepting you.
00:16:47.664 --> 00:16:49.647
While marketing, you pay retail for,
00:16:50.147 --> 00:16:50.386
right?
00:16:50.407 --> 00:16:51.227
You call in the air,
00:16:51.288 --> 00:16:53.190
you have lead generation, you have,
00:16:53.250 --> 00:16:54.951
I call those things the leaky bucket.
00:16:55.371 --> 00:16:56.613
You may pay, you know,
00:16:56.633 --> 00:16:57.833
the math runs something like this.
00:16:57.854 --> 00:16:59.655
You may pay eighty one dollars a lead.
00:17:00.712 --> 00:17:02.153
or a hundred and fifty to two hundred
00:17:02.193 --> 00:17:03.294
dollar acquisition cost.
00:17:03.355 --> 00:17:04.935
Are you familiar with Zocdoc and these
00:17:04.955 --> 00:17:05.655
kind of companies?
00:17:05.817 --> 00:17:06.457
Sure.
00:17:06.477 --> 00:17:06.557
Yeah.
00:17:06.576 --> 00:17:06.676
Well,
00:17:06.696 --> 00:17:08.597
those are transactional relationships.
00:17:09.118 --> 00:17:10.740
You pay more for them than you're going
00:17:10.759 --> 00:17:11.799
to get that first visit.
00:17:11.819 --> 00:17:12.280
And guess what?
00:17:12.320 --> 00:17:13.981
You pay whether they show up or not.
00:17:15.063 --> 00:17:16.723
One eight hundred dentists is another one.
00:17:17.344 --> 00:17:19.104
And so all of this,
00:17:20.085 --> 00:17:22.325
you're using your relationships to fuel
00:17:22.464 --> 00:17:24.165
everything from treatment case acceptance,
00:17:24.205 --> 00:17:26.925
better payer mix, to referrals,
00:17:27.266 --> 00:17:28.707
and then marketing savings.
00:17:29.307 --> 00:17:30.467
And the five-year button,
00:17:30.626 --> 00:17:32.086
in five years from now,
00:17:33.047 --> 00:17:35.627
my competitor is still renting patients
00:17:35.667 --> 00:17:38.148
from Google, Jarvis, ZocDoc,
00:17:38.269 --> 00:17:39.269
one eight hundred dentists.
00:17:40.419 --> 00:17:41.378
renting confidence,
00:17:41.419 --> 00:17:43.160
which from whatever office their
00:17:43.200 --> 00:17:45.539
associates are in, paying retail for both.
00:17:46.140 --> 00:17:47.240
And every January,
00:17:47.280 --> 00:17:49.000
the meter resets to zero.
00:17:49.601 --> 00:17:49.861
Now,
00:17:50.121 --> 00:17:52.102
if I own a training pipeline for dentists
00:17:52.122 --> 00:17:54.102
to choose on purpose and a patient base
00:17:54.122 --> 00:17:55.002
that recruits for us,
00:17:55.042 --> 00:17:57.083
that's the difference between compounding
00:17:57.663 --> 00:17:58.222
and rent,
00:17:58.722 --> 00:18:01.884
human capital and expense and marketing
00:18:01.923 --> 00:18:02.743
and lead generation.
00:18:02.763 --> 00:18:03.444
Does that make sense?
00:18:03.565 --> 00:18:04.884
It's a fundamental difference.
00:18:05.298 --> 00:18:05.598
Yeah.
00:18:05.719 --> 00:18:05.939
All right.
00:18:05.959 --> 00:18:06.499
So bottom line,
00:18:06.519 --> 00:18:07.779
the payer isn't going away.
00:18:08.460 --> 00:18:10.799
There are benefits or fee schedules or
00:18:10.839 --> 00:18:11.859
coverage limitations.
00:18:12.661 --> 00:18:13.320
Your argument,
00:18:13.340 --> 00:18:15.760
your article is about who gets the first
00:18:15.861 --> 00:18:18.842
vote, need first, coverage second,
00:18:19.122 --> 00:18:22.583
conversation, then third in that order.
00:18:23.123 --> 00:18:23.522
Because really,
00:18:23.542 --> 00:18:24.502
it sounds like you're saying a treatment
00:18:24.542 --> 00:18:26.084
plan quietly filtered through someone
00:18:26.124 --> 00:18:28.263
else's actuarial model isn't really a
00:18:28.344 --> 00:18:29.084
treatment plan.
00:18:29.523 --> 00:18:30.203
It's surrender.
00:18:30.243 --> 00:18:32.305
It's learned helplessness.
00:18:32.704 --> 00:18:33.565
That's right.
00:18:33.585 --> 00:18:35.526
Part three of your Inside a Platform drops
00:18:35.566 --> 00:18:37.467
next week on the operator on Substack.
00:18:38.366 --> 00:18:40.647
And if you're thinking about these
00:18:40.688 --> 00:18:41.608
questions today,
00:18:41.669 --> 00:18:43.388
make sure you stick around for the next
00:18:43.528 --> 00:18:43.628
one.
00:18:44.089 --> 00:18:45.150
Until then, keep operating.