Academy of Dental Masters

Mastering marketing can be a lifelong task. The game changes as time goes by, as new societal morals and communications become the standard.

Do you remember the early days of the web when the different internet service providers were duking it out for supremacy?  It seemed that AOL flooded American homes with introductory CDs weekly.  As time went by the free offer continued to elevate until it was over 1,000 hours!  Saturday Night Live did a comedy skit about people wallpapering with the disks!

While people were laughing, the other ISPs were scared.  Little AOL adopted an aggressive, unrelenting strategy of overwhelming marketing that blew its two main competitors at the time, Prodigy and CompuServe, off the map.  Like the conquering Borg of Star Trek, they were assimilated.

The secret that AOL Chairman, Steve Case, knew was the key to a multi-billion dollar success that led to the merge of AOL with Time Warner.

What was his secret?

The math.

Steve Case and his cadre at AOL figured out the cost to acquire customers against the value that customers would bring in the future. This is a math problem and a risk tolerance problem.

Once a prospect became a customer, he was unlikely to switch because at that time it was too much hassle to switch.

If you remember, few folks had much net savvy.  The people wanted an easy to use system they could understand.  AOL gave them that.  Once hooked on AOL, it was difficult to consider going anywhere else for the service.

What AOL figured out was this: what is the acceptable cost per lead based on the value per average sale.

Being able to spend more than anyone else to acquire a lead and then closing that lead into a customer gives any company a near insurmountable strategic advantage.

Marketing costs money.

One of the purposes of marketing is to acquire a lead that can then be converted into becoming a patient.

Different media cost different amounts of money.

Different media yield various numbers and quality of leads.

Marketing power comes from being able to use every source of leads even the expensive ones.

The key to this is the transaction size.  Transaction size means how much money the average customer will spend with you over his lifetime.  Theoretically, you could spend almost all the amount you knew was coming in the future to acquire the customer.  I am not saying you want to do this, but, in theory, it works.

The larger the transaction size, the more money you can afford to spend to acquire a patient.

The larger the transaction size, the more media you can use to get your message out.

The larger the transaction size, the more you can afford to spend on the quality of the marketing.

It is math.

You must know your average new patient value.  New patient value is the dollars generated on average per new patient seen within the first year in your practice.  This can be gotten from your office computer management system.

Unlike AOL and large corporations with deep pockets and fat wallets, your practice isn’t scalable.  There are limits to how much you can expand, limited by how much you can do with your hands at the chair.

Until you have reached your personal capacity limits, you can and should market aggressively to get as many new patients as possible that fit your practice model.

Secret: the type of patient you position yourself to be attractive to influences the average new patient value.  The more work the prospective new patient needs, the higher the new patient value.  The higher the new patient value, the more you can afford to spend to get them.

You could call this going after the big fish.  And as you know, big fish are harder to find, more difficult to land, require a different kind of bait and can take a lot longer to get into the boat.  The fishing gear is more expensive and you have to troll where the big fish live.

Secret: It is the last few patients that are so profitable.  Whoa!  How so?

Let me explain.  Once your fixed overhead is met by your production, any additional dollars collected are gi-normous in comparison to earlier dollars.  Your costs to deliver the dentistry after your fixed overhead is met are only the costs of your supplies, lab costs and other incremental costs.  The rest of it is paid for already!  You could be making 70-80 percent net on these!

Secret: Since the last few patients are the most profitable ones, you can afford to spend substantial dollars to acquire these additional ones, if need be.

Most Drs need help in increasing transaction size.  Even more need to understand the variable costs advantage to acquiring those most profitable patients.

There is yet another variable concerning this that has to do with time.  Can you guess what it is?

An article by researcher Francis Flynn points out that if you wait to collect on a favor, you may not collect at all!

Like Bread or Like Wine: What Happens to Favors Over Time? By: Noah Goldstein

So, are favors like bread or like wine?  According to researcher Francis Flynn (2003), the answer to this question depends on whether you are the favor-doer or the recipient of the favor.  Flynn suggested that immediately after one person performs a favor for someone else, the recipient of the favor places more value on the favor than does the favor-doer.  However, the recipient actually perceives the value of the favor to decrease over time, whereas the favor-doer’s valuation of the favor actually increases.  Although there are several potential reasons for this discrepancy, one possibility is that, as time goes by, people’s memory of the favor-doing event gets distorted; and since people have the desire to see themselves in the best possible light, receivers may think they didn’t need all that much help at the time and givers may think they really went out of their way for the recipient.

This blurb came from an article presented By Robert Cialdini in his ezine from Influenceatwork.com.

The ramifications for you hit home immediately.

Imagine you have just completed a beautiful case, gorgeous smile.  Your patient is ecstatic and grateful.  She is gushing out your praises.

The common response is to act shy and humble; say thank you quickly, and let it go.

Big Mistake.

If you do not seize this moment of favor you could be losing it forever.

Instead, seize it by the throat!

An example script: “Barbara, Thank you for your kind words.  We have trained thousands of hours in very complex dentistry to be able to do this kind of work. Frankly, it has taken a great deal of commitment, time, and money to acquire these skills.  As you know, Barbara, there aren’t all that many dentists who have the talent, training and experience to deliver these kinds of results.  Sadly, too many patients who need this level of dental expertise don’t know where to look or just think it isn’t possible.”

“Barbara, we need to ask you a favor.  Would you be willing to be an advocate for this kind of dentistry and actively send people here for this level of care?  Your support is what makes it possible to have a unique practice like this one.  Remember way back when we started you treatment.  I asked you then if you would be an advocate for fine dentistry – after we proved our ability to take great care of you.  Barbara, do you think we have proved our worth? “(The answer should be yes or there is something seriously wrong!)

“Barbara, we promise to take great care of the people you send here.  You know we depend on referrals form people like you.  Here are three of our cards for your use in sending other people to us.  Thank you, Barbara for your commitment and support.  By the way, we would like to do a short video of your success story about your dental experiences in our office. Can we do that now?”  (She’ll answer yes.)

Once Barbara does the short video testimonial, send her an unexpected gift via the mail to say thank you.

Seizing the moment of thank you is critical.  Left to it own, you could lose enormous amounts of active goodwill.  When you ask for help and favor at the moment of gratitude, The Thank You Moment, you help your patient actively “pay you back” for the service and grow your practice at the same time!

Share this with your staff.  Capture the favors and help everyone all around.

As a practicing dentist I get reminded every day about the issues we all face. One of these is: patients want certainty when they say yes to your care.

The reality is that sometimes treatment does not work in spite of your best efforts to ensure that it does.

This point really came home to me recently while I was in the hospital.  Two different patients with the same medicine applied. One gets well. The other does not. Why? Individual variability. There are often hundreds of factors that affect treatment outcomes.  We can’t control them all. Do patients get upset with the medical doctors? Usually not, because they understand that variability exists for them and have modified their expectations.

Admittedly, there is a slightly different situation than dentistry here. Treatment medically is considered non-elective. The patient has no choice.  Most dental patients consider most of our work is elective.  Whether true or not, that is the perceptual reality through which they view our care.

Our response is to paint a picture of assured success of therapy to remove the various risks of care.  This places an unfair burden upon us when treatment does not work out through no fault of our own.  Performing therapy on the human body is a challenge.  Performing that therapy on the emotional bundle that comes with that body is often a bigger challenge.

Sometimes it is our fault.  After all there are hundreds of steps in many of our most common procedures, any one of which can screw up your result. We should take responsibility for these and fix them.

It is the ones that we aren’t responsible for failing that I am talking about.  I am talking about the root canal that failed, the implant that didn’t integrate, the graft that didn’t take, the third molar site with the altered healing response. There are many, many more. These are individual responses that are beyond our control.

OK, so what is the answer you say? The answer is quite simple.

Tell them the truth in a diplomatic way. Tell them that there are risks of things going wrong based on individual variability. Do so, all as a matter of fact.  Treat this as just a part of your ongoing discussion about care. Encourage your staff to do the same. Tell your patients these are risks they have to take.

Now minimize the risk for them with your assurances, your past successes, your experience, treatment statistics and what they need to do to help ensure success. Paint a desirable picture that includes the future benefits of care. Do all the things you do to get a patient to say yes normally.

Include in your treatment consults the concept of the unplanned discovery that can alter your treatment and cause increases in fees. Let them know how you will handle it. Get the patient’s permission beforehand to do what is necessary at the time of therapy so you aren’t stopping midstream.

All of this treatment discussion is delivered to the patient as regular everyday “this is how it is.”  No over emphasis on the risks, just a frank admission that things can go wrong, however unlikely.

Doing this relieves much of the pressure that most of us put ourselves under.  The side benefit is that when you are more relaxed you are less likely to commit operator errors and you enjoy yourself that much more.

Doctor, your credibility goes up when you tell your patient the truth this way. The results are a more trusting patient with realistic expectations, a happier patient – and a happier you.

Imagine a fence that encloses your group of patients. This imaginary fence keeps your patients loyal and coming to you. The fence is built of customer service, dentistry well done, expectations met or exceeded and patient communication.

The fence easily develops holes, breaks and breakdown. When your patient is in your office, the good experience keeps your patient loyal. It is a requirement for your patients to like you. You do have to manage their expectations.  The quality of your relationship is important. The visit itself creates TOMA (top of mind awareness.) The fence is strong and in good repair.

The longer your patient is away from your office and your care, the greater the chance that a hole will develop for that patient in that mental fence you created.  Life is happening all around. People forget. Ask most any person the name of their dentist. Often they cannot name them at all! Most will have to think about it. The memory you leave with your patient is  Poachers appear and make appeals to join the poacher’s herd.

Whether or not the poacher is successful is dependent on your frequency of communication, personal touches and follow-ups. These steps could be called “the renewal of the liking you” and the deepening of the quality of the relationship. Dentistry is still a personal service.  It can’t be treated any other way. Ignore your teeth and they will go away… the same is true for your patients. If you don’t care for your patients and communicate this well and frequently, you will lose patients.

If there were any one thing you could have more of what would it be? If you asked Bill Gates, he would say time. It is the one thing all of us have equally.

1444 minutes a day is all there is.

So why is it that some people get so much more done with their minutes? The simple answer is how they spend it.

The brightest, most capable people don’t always rise to the top. Talent undeveloped is virtually worthless. It is how one chooses to spend his time coupled with his talent and discipline that determine how far one goes.

Leverage

This program is a leverage machine. It is designed to get you where you want to go faster and more completely than going it alone. It saves the one thing you can never get more of. You can always make more money – you can’t make more time.

It is what you do with what you learn that makes the difference.

What have the most famous innovators, inventors, businesspersons, scientists and leaders had that has catapulted them to the top of the heap? Each has had a talent for what they do. Each has been passionate about his/her field. Each learned to leverage his/her learning.

How do you leverage your learning? (Think speed of learning, depth of understanding and application.)

The foremost way is to ask the experts what they know. Discover what is already known from the best in their fields. This step alone saves time, money and effort. It allows you to concentrate on the majors and leave the unimportant minor items unattended.

You ask questions. “I ask questions” was the mantra of DaVinci. (Born illegitimate, he could not be part of the most desirable business and notary guilds of Italy. But, he was free to go into the arts.)

Jonas Salk knew what the experts said about creating a vaccine for polio – you had to use live virus. He questioned this. He developed a vaccine by killing the poliovirus using UV light and injecting the dead virus. His outside the box thinking brought polio down to 10 cases a year from its previous 50,000 cases per year!

You consider how you can apply it. Attaining new data without considering how you can use or apply it robs you of its true value.

How you can think with it? What new revelation comes to you in light of this new information?

You compare it to what you already know.  Beware of an existing mindset that disagrees with the new information – this will often lead you to disregard the new data. How does this new info “fit?”

You question the validity. What might be only partially true? Is this piece of info always right?

You look for patterns in the information and compare these to the patterns you already know about. How does the data fit with what you already know? Look at all the various places the new data could enhance your thinking.

You research the materials referenced and footnoted. What are the sources and how reliable are they?

Figuratively and sometimes literally, you take the entire body of information and turn it inside out, upside down.

You look for places the new information agrees and places for which it disagrees.

When you digest the information this way, your recall of the material and its usefulness increase 500-600 %!

Here’s to your “digestion!”

Emma was a regular gal with a messed up “grille.”  She had pretty facial features and was fairly attractive for a forty-something year old.  You would have thought that a person with her socio-economic background would have never let herself get in such a condition because she was upper middle class.  She was married and had three kids – one in college and two about to go there over the next three years.

She had come to me because she knew she needed the help. We had handled everything pretty much as usual with her except one thing – somehow we had never broached the subject of money prior to the consultation.

She had readily agreed to our suggested care and was anxious to get started right away.

Then we started to discuss the fee.  She was flabbergasted.  She said she had expected about one third of the fee.  Her spouse was likewise upset. They said they wanted to think about it and get back to us.

They thought about it all right; two days later, they requested copies of her records to take to another office.

Has that ever happened to you?  You know how frustrating it can be to work so hard and then to come up empty.  It feels like a personal rejection and discourages you no end.

It is the kind of case presentation result that has dentists rejecting complete diagnosis as the standard way to operate.

The thought goes, “I can get at least this work accepted and do something rather than nothing.  Plus, I don’t want to spend all that time preparing for a consult and just have her shoot me down.”

Unfortunately, not only does incomplete diagnosis and presentation hurt the patient with care that falls short; but you also run up your overhead and make far less dough than you should.  It is a form of double loss.

Complete diagnosis and accepted treatment is a form of double win – everyone gets what they should get.

Let’s get practical for a moment though.  When should money be discussed?

Patients that have no idea of the severity and depth of their problems cannot be expected to say yes to any sizable treatment plan.

The value proposition does not exist until a problem is FELT and understood.  Only then can one present a fee.

But hold on.

What about the patient for which you present the fee at the end of the value proposition build who gets blown out of the water leaving you looking skyward to the gods for solace and muttering to yourself about the waste of time?

Yep. That can happen and does every day in practices all across the country.

What is the Doctor committed to excellence to do?

This can get a bit tricky, but here goes: You present the idea for a possible fee at the completion of your clinical diagnostic exam. The patient has heard your talking over her to your assistant describing all the problems.  She has felt your gentle and through touch.  You have gone over her needs and wants.  She “gets” that she has a mouth full of problems.  You then order the complete diagnostic records to complete her complete dental physical.

If she agrees to the diagnostics, then either you or your assistant needs to have a little chat to bring reality to the heart and mind of your patient.  It is at this point, where you have gained a bit of trust and your patient has been immersed with you in your findings that she is ready to hear about a probable range of fees.

You should make this range quite large and simply tell her that it will depend on what your diagnostics reveal and how good she wants to have her teeth again.  This range should go quite high as well as having a possible low range.  Doing this creates a mental frame for her to think about in terms of your fees.

You are setting expectations.  These are key.

If your patient rejects them immediately and you have established at least some level of rapport and shown her the depth of her problem beforehand, congratulations.  You have just screened the patient sufficiently to know what you cannot do.  This is the patient for whom you prescribe maintenance care and perio therapy.

What usually happens is that your patient is now set up for and expects the fees you present at the consultation. No surprises are a good thing.  Now you cannot only help her put a smile on her face but one on your own as well!

By the way, Emma is fictional. Many years ago, I had way too many Emmas.

It was only after untold unsuccessful experiences that I discovered this workable method to create the expectancy of fee and avoid the shock of surprise.

To your case presentation success…

It isn’t done on purpose. It isn’t done knowingly. Yet, it can be a killer.

It is done because of ignorance of the requirement of an imagined preferred future fully acted out beforehand in the theater of the mind.

This imagined future is the one made of dreams, desires and aspirations. It has magic and magnetism that pulls one through the morass of everyday living. It reduces complexity. It guides your thoughts.

Alas, I have gotten ahead of myself.

First, an explanation.

All of us have set targets, objectives and goals – implied, written or considered. Of course, the most powerful of the three is written. Many of you are aware of the oft-cited Harvard study of MBA grads of 1950. Thirty years later, the graduates that had set written goals (3%) had made more money that the other 97% combined.

So let us suppose that you have made some of your own for your practice and your life.

The acceleration of achievement occurs early on after setting the goals. Your mind becomes focused. Now your activities and thoughts become targeted toward acquiring the knowledge, skills and understandings necessary to accomplish what you set out to do. This is a future focus while still being in the present.

You do the actions necessary to accomplish your desired future. You get busier. More “stuff of life” is happening.

As you approach the accomplishment of your goals, the ceiling you have set for yourself, the work of getting there can get tougher. More and more the game becomes filled with all sorts of actions that just must be done, but get very little result. You are working harder, longer and less satisfyingly.

THIS IS A SURE DANGER SIGN THAT YOU NEED TO RE ADJUST YOUR GOALS HIGHER OR TO A NEW LEVEL.

Why?

You are running out of game to play. Once the ball is put across the goal line and the time set for the game is over, there is no more game. People like their games. This is yet another reason to put a definite time of accomplishment on your goal – just like a game has a definite time limit.

You and every other person of achievement must have a game to play that you enjoy, that has challenges, barriers to overcome and obstacles to surmount.

Show me someone with no game, or a completed game without a new one to play or uninteresting game and I will show you an unhappy person.

This is why people hold on to the game they already have, even when it has outlived its once proud challenges. These games now extend themselves, become increasingly complex and increasingly less satisfying. This is the classic example of working harder with less and less result. Complexity becomes the norm.

You have created your own ceiling that you have made impregnable.

The key is to re-set or re-adjust your goals higher. You are literally creating another game to play more worthy of you and your best efforts. Now you have simplicity again. The targets are crystal clear. Importances show themselves; the un-important (but seemingly necessary) fall away.

Goals accomplished should be celebrated and re-set pretty quickly. Failure to do so can be as bad as an indefinite, goal-less future – for the magnetism of the preferred future dwindles to nothing.

Now there is more to it. But that I will leave to another day.

I will leave you with this thought: Do you need to re-visit your goals?

I was sitting there on my doctor’s stool listening…to the second new patient in two days tell me about his highly charged prior dental experiences. His face grimaced and contorted and went through a series of gyrations reflecting his mixed emotions as he related his perceptual reality of his past.

The miss-emotion coming out as this new patient told his story was the recurring mix of sadness, anger, frustration, pain, disappointment and varying degrees of hopefulness. He was grasping for help, but was still a bit uncertain if he could trust me and my team yet – even as he wanted to.  Here was yet another patient emotionally wounded to the point of disability – disability of rational thought, disability of decision and disability of self-worth.

Let’s examine all three. The first is disability of rational thought. When a patient feels you have rejected them emotionally, it literally alters their ability to think straight. A quick example to illustrate: Just remember a time that you got so mad that you wanted to hit someone (or did hit someone). Was that rational thought? In hindsight, you likely answer was no.[ If you are still feeling upset about that prior situation (miss-emotional) then you could have said yes, “I still want to hit them” ] The point is that emotional pain carries forward from the past and lingers and often permeates thinking. This is the “reason” that some patients seem to like to tell us: “I hate dentists.”

Think of another time when you experienced loss: the death of a loved one, the loss of a job, the denied acceptance to the school of your choice, someone else getting the promotion you felt should be yours. The deeper the upset at that time, the less able you were to think straight, to think through things with reason.  It may not have been a total loss of rational thought, for it is on a gradient: the deeper the emotional wound, the less rational you become at that moment.

(Trial attorneys use this misemotional lever all the time to emotionally strike (upset) a witness on the stand to the point that the witness says something that he wishes he hadn’t!  They also use it in depositions to create a fear of being made to look foolish, stupid, or irrational and therefore help “force” a settlement before trial.)

The second of these is the disability of decision.  Without our emotional physiology being activated, man is incapable of making decisions at all. In certain brain injured patients the missing emotional physical contribution to your thinking stops even the simplest of decisions! The opposite part of this is also true: when our emotions are overwhelmed, you or I can’t, at that moment, decide. When forced to decide, we select the decision that seems safest, almost always this means NO.

When meeting an emotionally charged patient for the first time, we need to defuse “the overwhelm.”  I purposely use the term defuse for the patient’s misemotion is akin to a figurative bomb that will blow up and destroy every thing in its path including you and all possibilities of getting a yes and success.

The third of these disabilities, disability of self-worth, doesn’t get much attention; nevertheless, it is important if you care about your patients.  How do you feel about yourself when you see that you have failed at something?  Can you imagine how it would feel to fail at something that you “know” you should succeed in doing…like being able to sit in a dental chair and allow someone to help you get your teeth fixed? Failure of all kinds can drain your and my sense of self worth.

Look we are highly educated, able, successful people. Can you imagine the less able and what it does to them? How about “the very able” in all other facets of their lives who can’t self-manage a dental experience? Do you think these people question themselves because of this disability? Oh, yeah-they do.

It really is quite simple here: when we help the patient who has emotional dental disability get through her appointments and complete her treatment we have raised her sense of personal self worth. For some, the self esteem screams to new levels, new successes are somehow magnetized to our newly rejuvenated patient.  They come almost magically. Promotions parade through their lives, often in rapid succession. New relationships are created.  Our formerly single patient finds the mate of her dreams. Not only does our patient look better, she also feels soooo much better about herself. She carries herself differently. She walks with a quiet confidence. She rubs off this positive, glowing energy on those around her.  You can’t necessarily see it with the eye, but you “know it is there”. It gladdens the heart.  Now that is a positive ascending spiral. Creating that is why I became a dentist.

It used to be that our patients, like the rest of America, choose services and products based on price and quality. Not so much anymore. What happened and where do you go from here?

To describe it fully requires a history lesson going back to the 1760’s England and the change in the means of production.  For thousands of years the relative productivity of the worker was stagnant.  It was the advent of the means of mass producing wanted items with quality that was better and at cheaper prices that catapulted England to a hundred year championship of global economic supremacy. I will skip forward to the state of consumers now.

What is the state of quality in the consumers mind? Quality products are found everywhere. Products last longer. Many get cheaper. Quality is now the expected for every product out there and any product that doesn’t cut it is soon gone. Quality as a marketing edge is near impossible unless the company has proprietary products or patents that prevent others from competing with them. Quality has become just the expected standard.

What about prices? Yes, these are still important, but consumers have more discretionary income than they ever had. The affluence of the American economy is because of the relative freedom of the markets, political stability, transportation, natural resources, infrastructure, communication systems and the profit motive. It took two hundred years of putting all those pieces in place but the American economy has led the world since the early 1900s. Americans have so much money to spend because the basics of food, clothing, and shelter are already met. Since survival is assured, the consumer thinks,” I’ve got money to spend on stuff I want.”

An easy example of the “I want” is a pretty smile. This has led to the birth of cosmetic dentistry. The Crest white strips bleaching system made Proctor and Gamble somewhere close to a half billion in profit by now I would venture to say.

There is a second reason that people buy that is overlooked. It is important to us as dentists. People buy things to avoid things they don’t want. They don’t want to lose their teeth. They don’t want pain from their teeth.  The dichotomy is that people associate dentists with pain, yet dentists are the ones who help them avoid pain! No wonder patients seem conflicted.

Patients don’t want to lose their teeth. (Purposeful Repetition) That is why people with periodontal disease have periodontal treatment to keep their teeth. In this case, the consumer doesn’t want to lose her teeth more than she doesn’t want to have treatment done and pay money for the service.  But the moment the patient doesn’t feel threatened with tooth loss or tooth pain, the relative value of care goes down.  This can cause patients to delay or deny further treatment. Literally, the treatment and fee become more of a “don’t want” than the threat of tooth loss.

What about the patient with a tooth missing in the front? How often have you seen a patient with a disaster among the posterior teeth and the patient focused on how the front ones look? This is a case of wanting an acceptable smile and not wanting missing front teeth. Unless you can make the bombed out and missing back teeth a problem to the patient she will not have much interest in treating them.

People are motivated by fear of loss more than by the advantages of gain. Do you get the implications for your practice? I can make an ethical argument that we as a profession should keep patients in a dynamic tension of the fear of loss of their teeth. It could change compliance dramatically.

Disaster case patients come to us with a triad of “don’t wants”. They don’t want the pain their teeth are giving them, they don’t want the pain of social embarrassment and they don’t want not being able to chew and function. Literally, they don’t want the disability their teeth have created for them. There is the other side of this too: what the patient says she wants: a pretty smile, chewing ability, look younger, pleasant breath, social acceptance.

What she won’t say typically is that she wants to feel better about herself. But it is there and should be used by you to influence her.

Few recognize the health implications – these should be “piled on” to build further value.

You should play the cards that your patient deals to you and cheat by adding the cards you hold. Truthfully, it is your duty to stack the deck so the patient says yes

Why do we buy anything? The answer is because it helps us to have a better life.

So what are the levers of motivation and persuasion that are available to you with this affluent society? More on that next time.

The difference between delivering a custom service and selling a product is huge. Products can be sold for less if they are bought for less and you can sell a lot of them. This is the secret of the Wal-Marts of the world. They have low mark-up and sell 400-800 % more of them in a single year per store.

The store that turns over its inventory only 4 times a year has a hard time competing with one that sells for less, turns inventory over two to eight times faster and makes more profit based on that volume. Just ask Kmart, who has now joined up with Sears. This is a case of two big, dumb companies getting together- Dumb and Dumber – you pick which is which. Neither one had a winning strategy. I doubt seriously that together they will evolve a coherent one. This just proves that multi-billion dollar corporations can do very stupid things and often do.

Custom services on the other hand, can’t lower its overhead costs significantly based on high volume.  Yes, fixed costs remain the same, but variable costs seem to increase. While there is a moderate increase in profit when more units are done, the service itself becomes more complex and has increased potential for errors.

This difference between products and custom services gets confused by patients. They have been “trained” that more volume equals lower price from product advertising. The opposite is true for custom services. The fees should increase as units increase because complexity increases geometrically(or nearly so.)

You can’t simply multiple your single unit fee by the number of units you are doing to arrive at a fee. It costs more to deliver the service and risks are higher. Failing to charge more for work that costs you more to deliver and that has increased risks from possibility of errors is near certain to zap any profit that should have been yours

This concept needs to be explained to patients (and staff) simply so they understand and accept the fee differences.