The rise of outsourcing in the United States gained significant momentum in the late 20th century, marking a pivotal shift in the way businesses approached non-core functions. The 1980s and 1990s saw a surge in globalization, technological advancements, and increased competition, prompting many industries to explore more efficient and cost-effective business models. Companies, including those in the healthcare sector, began outsourcing various tasks, such as billing, customer service, and information technology, to specialized service providers. This strategic shift allowed businesses to tap into global talent pools, leverage economies of scale, and focus on their core competencies. The outsourcing trend has since evolved, with orthodontic practices now considering it as a viable option to optimize their operations and enhance overall practice management.
 
Given this summary of outsourcing, one should not blankly assume that outsourcing leads to efficiency and cost savings. In fact, the opposite order is what makes sense. Out or insourcing should be done with the goal of efficiency and cost saving. In this blog post, I would like to focus on the efficiency and cost-effectiveness of the clear aligner fabrication for startup offices.
 
The most common area of outsourcing for most orthodontic startup practices is in their clear aligner fabrication. Most commonly using a big company such as Invisalign or Angel Aligners to fabricate aligners and package them ready for use. The opposite to this would be systemizing in-house aligners from the get-go from day one. In truth, at the time of writing this article, no clinician can truly insource the clear aligner manufacturing process entirely; at the minimum, you would need the software to section teeth and stage movements. This being said, in-house aligners provide more opportunities for clinicians.
 
Do in-house aligners increase the efficiency of an orthodontic startup office?
There is one area in which startups do better than established offices, which is capacity. There is going to be a lot of downtime for the doctor or the team in between patients or on admin days. The downtime can certainly be used by having the team focus on in-house aligner fabrication. There is nothing more efficient than having someone else make your clincheck, for you to finesse it and again, having that someone else fabricate and package the aligners.
 
The in-house aligners, however, have better turnaround time. You can scan today and see your patient later on the same week to deliver their attachments and aligners. The average turnaround time for outsourced aligners is about 3-4 weeks. Invisalign allows providers to “rush” cases and have them back the following week.
 
 
Are in-house aligners more cost-effective than outsourced aligners?
To answer the above questions, we need to do some math and make some assumptions. For the purpose of this argument, I use Invisalign and Angel Aligners as examples of outsourced aligners and use their pricing to compare. For in-house aligners, I’d use Archform as an example of a pretty cost-effective aligner system. At the time of writing this article, Invisalign has a promotion which allows some discounts for a comprehensive case to allow the final lab fee to land around $1400; Angel Aligners also has a promotional pricing of $850 lab fee for a full case. Here are probably the most conservative cost breakdown for in-house aligners:
1. Software use: $50 per case
2. Resin cost per arch: $1.5
3. Aligner plastic per arch: $2.5
4. Packaging bags for aligner set: $1
5. Other auxiliary materials such as alcohol for wash: $0.5 per set
6. Assuming your RDA is paid $20/hr and takes them 15 mins total for print/wash/trim/fabrication: $5 per set
 Total cost per set of aligners: $14.5
 
Please note the above numbers do not include the cost of the hardware purchase and repairs. The resin used is a generic resin such as Elegoo and the printers are entry-level Epax or Phrozen 3D printers. If dental-specific printers or resin are used, the cost will be even higher. Considering the lowest fee for a comprehensive case out there from a reputable company, Angel Aligners, which is $850, your cost with in-house aligners will essentially be the same as outsourcing if you were to use a total of 27 aligners per arch in your treatment; this is inclusive of all refinement. Comprehensive cases often need more than 27 aligner sets during their treatment. In short, in-house aligners are only cost-effective in mild limited treatments.
 
For full objectivity, I am comparing the least expensive set of in-house and outsourced aligner fabrication processes. Comparing the Angel to more expensive in-house setups makes outsourcing even more cost-effective. Comparing in-house aligners to Invisalign makes in-house a more affordable option in cases needing less than 50 sets of aligners.
 
How does aligner fabrication affect your cash flow?
Cash flow is likely to be the number one pain point for any startup practice. Outsourced aligners usually come with Net60 financing, meaning the entire lab bill is due in 60 days. Lab bills can be particularly challenging for startups when the cash flow is not there to support it. On the other hand, in-house aligners are the unbeatable champions of cash flow in the short and mid-term range. You only pay for what you need, so if you require 20 aligners, that is what you pay for. This approach can significantly reduce the stress on the practice's cash flow.
My overall take on insourcing clear plastic is that clear retainers must always be made in-house, but insourcing clear aligners helps in short run with alleviating cash flow pains but can actually be more expensive in long run for comprehensive aligner treatments. 


Disclaimer: Dr. Kevin Baharvand has no financial interest in any of the products or services mentioned in the blog. 

Product Overview and Utility:
 
Cloud9 Orthodontic Software is designed to streamline orthodontic practice management, providing a comprehensive solution for professionals in the field. Its primary utility is in offering orthodontic practitioners a platform to efficiently manage patient information, treatment plans, and scheduling.
 
1. Performance and Quality (4 stars):
   - The performance of Cloud9 Orthodontic Software is quite well, meeting the basic requirements of orthodontic practice management. Cloud9 operates entirely in the cloud, eliminating the need to download additional software except for the Twain connection between X-ray equipment and Cloud9. The overall loading speed is satisfactory, with few disconnections reported in our practices over the past few years.
 
2. Features (2 stars):
   - Cloud9 Orthodontic Software provides essential features for orthodontic professionals but may lack some innovative functionalities. Notably, features such as electronic signatures, patient hub, two-way texting, appointment reminders, and reputation management come at an additional cost. A additional significant drawback is the need for multiple phone lines for texting, reminders, and calls, potentially causing confusion for patients.
 
3. Ease of Use (3 stars):
   - The software's clinical interface is generally user-friendly, offering an intuitive layout for managing orthodontic tasks. However, the administrative side, including ledgers, is somewhat counterintuitive, presenting a steep learning curve for users.
 
4. Customer Service (2 stars):
   - Cloud9's customer service has experienced a decline since its acquisition by PlanetDDs. As of the writing of this article, contacting Cloud9 customer care is not possible through direct calls; users need to open a ticket and wait for a reply.
 
5. Value for Money (3 stars):
   - Cloud9 Orthodontic Software provides moderate value for the cost, meeting essential needs. However, perceived as potentially overpriced, especially when factoring in additional features. The all-inclusive version may cost around $1300-1400 per month, excluding initial licensing, training, and implementation fees. Prices may vary significantly among offices based on initial promotions.
 
6. User Experience (3 stars):
   - The overall user experience with Cloud9 is positive, but dissatisfaction has been expressed regarding the decline in customer support post the PlanetDDS takeover and the additional costs associated with extra features.
 
7. Reliability (5 stars):
   - Cloud9 Orthodontic Software is generally reliable, with occasional minor issues.
 
8. Innovation (3 stars):
   - While Cloud9 was once a leader in orthodontic PMS innovation, it now strives to keep up with other software's features. The software lacks significant innovation, offering standard features without introducing groundbreaking functionalities. Their mobile version is far from easy to use. 
 
9. Compatibility (4 stars):
   - Cloud9 is compatible with various systems, minimizing compatibility issues for users. Ongoing efforts to ensure seamless integration with other platforms would further enhance the software's appeal.
 
10. Customization (4 stars):
   - The schedule and clinical side of the software are customizable, but the administrative side has limitations in terms of customization.
 
11. Feedback and Reviews (3 stars):
   - User feedback for Cloud9 is mixed, encompassing both positive and negative comments. It's worth noting that we have decided to transition away from Cloud9 for our practices around April 2024.
 
Alternative Options:
   - 1. Greyfinch
   - 2. Ortho2
   - 3. Wave Ortho
 
Disclaimer: Dr. Kevin Baharvand has no financial interest in Cloud9/PlanetDDS. 

​UCR stands for Usual, Customary, and Reasonable. It is essentially what you would like to charge for someone who is paying all expenses out of pocket or not in network with their insurance plan. You must set your UCR as one of your early tasks before opening your startup. Numbers can be all over the place, and there is no exact formula to determine that. I hope these tips can help you set the UCRs to what is best for your practice:
 
1. Demographics and Local Competition: Take a good look at what differentiates you compared to solo or corporate competition. If you are already working in an office, use that as a starting point and set yours higher or lower depending on your answer to the differentiation question. You need to position yourself well in the market, not too high or too low.
 
2. Use ADA Annual Survey as a Guideline: Take it with a grain of salt as most participants are not orthodontists.
 
3. Use Gaidge Summary of Dental Practices: Gaidge has more data compared to ADA from actual orthodontic offices, so their information is likely to be more reliable. However, most startup orthodontic practices do not use Gaidge, so their data is skewed towards established mid to high-performing practices.
 
4. Get in Touch with Insurance Companies: Obtain their fee schedule. Aim to be at least 30-40% higher than the best-paying insurance. Insurance fee schedules are set based on the demographics and number of the local providers.
 
5. Talk to Friends or Colleagues: Keep in mind that their demographics may be different than yours.

6. Tiered UCR Pricing: You may choose to have multiple levels of pricing for the same code. This way, you can be compensated fairly for the complexity of the clinical case or patient management.
 
A common question we get is whether UCR even matters if your practice is in-network with insurance plans. The answer is a strong yes! Your UCR will be a strong tool for negotiating your fees with insurance plans at the startup process and also down the road. My last piece of advice is to be diligent in adjusting your UCR yearly in parallel with the inflation in service industries.

Change prompts a spectrum of emotions, from anticipation to frustration. Within the structure of everyday routines, team members often find comfort, making the prospect of change a daunting one. Yet, for practice leaders, recognizing the need for dynamic evolution is imperative—a strategic response to the evolving demands of the industry within and outside our practices.
 
The initial stages of change, such as team restructuring or transitioning to new software platforms, may present challenges. However, beneath these disruptions lie opportunities for process improvement and increased efficiency.
 
I remember when my first team member submitted her two weeks' notice. She had to leave my team due to her husband’s job change. Oh man! I felt so let down. I was genuinely naïve enough to think she might one day retire with us. Fast forward a few weeks, we replaced her with a new member and never looked back. We were able to implement changes during the transition with no resistance and became a lot more efficient. In fact, most of the team members you start your startup with will not be with you after a few years. In my opinion, it's because your practice grows faster than they do. As I said earlier, change can be daunting for some.
 
2024 is the year of changes in our practices. We are planning to retire Orthofi, Cloud9, and Align in our practices. To do so, we need to have systems in place to avoid setbacks. We also need extensive team training for both learning and executing the new programs. In a nutshell, our entire new patient onboarding, financing, and communications will change. My goal is to lower our overall overhead by about 10% by the end of 2024.
 
Navigating change is a strategic process—a measured response to uncertainty. As practice leaders, our role is to guide our teams through these shifts, offering support, reassurance, and a clear vision for the path ahead. There are those who will tag along and others who may find comfort elsewhere.