EP 66: Covid-19 Recovery Update

In this episode of the Double Your Production Podcast, we’re sharing an audio segment of Wendy and Dr. John from their latest live video series.

This series is focused on tracking COVID-19 and the impact it has had on dental offices and the economy nationwide.

Click here to watch the video on Facebook.

For more updates from Wendy and Dr. John, follow The Team Training Institute on Facebook.

Welcome to the Double Your Production podcast with The Team Training Institute, the one place designed for dentists and their staff who want to grow their practices by following in the footsteps of those that have done it, who are in the trenches, who know exactly what you're going through. And now your leaders, the stars of the podcast, Doctor John Mees and Wendy Briggs.

All right. Hey, everybody. I'm Doctor John Meis. I'm here with Wendy Briggs, and we are The Team Training Institute, and we're here with another COVID-19 live update. How you doing, Wendy?

I'm great. It's been a little while, so it's good to be back with everybody and talking through some more recent information, right?

Yeah. So much has been learned in the last months. It's pretty crazy. We were tracking very carefully kind of the mismatch of data and the messaging coming from various agencies, from the government, from the media. And so now that things are starting to square out, it's interesting to see really where everything really is, when you really look at the data. So here's what's happening. Why don't you walk us through this, Wendy?

Yes. So this is just the latest update from The New York Times on where we are in the state of all things COVID-19, right? So worldwide there's more than 5 million cases, and tragically 332,000 deaths worldwide, the best we know, right? Some of the data's questionable, slightly suspect. There's been some adjustments maybe even in our country about how these deaths are measured, but that's kind of where we are, which is both good and bad, right? It's good, because we're not even close to the initial models. I remember seeing one model that said we could have as many as 2.5 million dead in our country alone, and thank heavens we haven't come to that. Those models have been off by as much as 800% in some of those models, which is fortunate. So this is just kind of the status of where we are as far as the disease and the virus is concerned.

Yeah, very good. It's delightful that it's not as scary as we once worried about. And we've been watching for people coming up with strategies that kind of make sense knowing what we know now. Very easy to criticize some of the early decisions made, but that's really Monday morning quarterback, and we don't want to do that. We want to look at how do we move forward in a way that makes sense, and one of the best pieces of information that I've seen on this is from McKenzie. It's a large consulting firm, and they came up with a strategy that I think makes a lot of sense. So testing, everyone's saying testing, testing, testing, but they really haven't had a clear strategy on what to test and why.

And so because there weren't enough tests, they were testing only the very sickest, which is what gave us those crazy, inaccurate fatality rates, because they were measuring fatalities against positive tests, but they were only testing the very sickest. So that's like testing cancer survival rates, when you only include people that have stage four type cancer. So the way that it was being done was wildly inaccurate, and now we're starting to get a much better sense of what the real fatality rate is, as you mentioned, Wendy, hundreds of percent lower than what was being suggested early. So for testing it does make sense to test people who are symptomatic. If they have it, that's important information to know. It's also important to be testing antibodies, right? And body test tests if your body has had an immune response to it meaning you've been exposed, your body filed up, you may have gotten sick, you may have not gotten sick. But you have now antibodies to it. We still don't really have a very good answer to what type of immunity to people have once they've had it. Do they have complete and lifelong immunity? Probably not. Do they have some immunity for a period of time? Probably so. But we still don't know.

There is an assumption and you see it frequently stated in kind of the scare tactic media that, "Oh, gosh. We found four people who had it and now they have it again." And those kind anecdotal stories really don't give all the information we'd like to have. Though, they certainly aren't any kind of proof. So doing antibody tests certainly makes sense. And then testing populations to see how it's spread.

So we know that this has been evolving. So we know that they said it could be transmitted through aerosols. And then they said, "Well, it's going to be very difficult for it to be transmitted through aerosols." It could be transmitted on surfaces. Well, now we know it's very difficult for it to transmit to surfaces. So if you test everybody in a population and see how it spreads gives you information on how to fight the virus and how to keep yourself as safe as possible.

Now, we know that everything that's been done so far is solely to reduce the speed of the spread of the virus. It's nothing to cure it, nothing to prevent getting it. It's simply to slow it so the healthcare system is not overwhelmed. Much of the public has gotten confused. They think the things that we're doing now are preventing them from getting it. No. They're slowing it down. They're not going to get it now. But they're probably going to get it somehow, someway, sometime. So for those people who test positive, contact tracing.

So figuring out who they spent time with. We know that it takes prolonged face to face exposure is the lastest that we're hearing. And that prolonged is roughly about a 15-minute period. So they are going back and tracing. We should be, and some states are. Obviously, this is a whole new system and we've got a ton of people to do this with. But going back and finding out who they have that kind of face to face, that amount of time with, and telling them that they have been exposed. And so contact tracing is how we really slow down the spread.

Next is quarantine. So, I mean, this is kind of common sense. And go ahead advance to a couple clicks. Thanks, Wendy. So, if you've been in contact with someone, right, it makes sense to quarantine for a period of time. If you have a flu-like illness, it makes sense to quarantine for a period of time. And if you're high-risk, it probably makes sense to quarantine for a time. The problem with that one is you're going to be quarantining for a very long time. And is that the best for our population's health? Quarantining has it's own struggles. We're seeing suicide numbers go up dramatically. So when we don't have contact, we have mental health issues. We have addiction issues.

And so I'm not sure long-term quarantining is a great answer. But those high-risk, one strategy would be to quarantine until we have a treatment. And for a treatment, hopefully, we will find a drug or a combination of drugs that are currently available. Most of the money is not going into testing of that. Most of the money is going into trying to find new drugs. Obviously, there's a lot more revenue and profitability in new drugs than there is in the available drugs. And that's where the money is going because that's where it's going to have the biggest impact on the companies that are doing this research. And the last thing is a vaccine. So if we get a good treatment or a good vaccine, those high risk can come out of quarantine.

A vaccine's going to be tricky. I know there's companies that say, "Yeah, by December, January we're going to have a vaccine." But for those of you who were around during the HIV time, you may remember in those first few years, "Yeah, we're going to have-- we'll have a vaccine up very quickly, very soon, very soon." And it went on and on and on. And now, 30 years later, we still don't have a vaccine. So we can't depend on the vaccine coming. Obviously, I hope it does. I hope they come up with something that works very well, that's safe. I hope the public complies with getting vaccinated so that those people who are at high risk can come out of their caves. But yet to be seen.

So what's happening in the economy? The Fed Chair said over the weekend-- he was on one of the new shows, which is a very unusual for a Federal Reserve Chairman to be on a new show. They usually are under the radar. They usually don't say much. They usually have highly, carefully worded documents that they release and that's usually it. And it was very interesting to watch our Federal Reserve Chairman. And he talked about an economic downturn without modern precedent. He talked about unemployment rates reaching in the 25% level, very similar to the Great Depression unemployment level. So we are in for an economic bump here for sure and it should be pretty significant. So in today's Wall Street Journal, even in recovery, some jobs won't return. We're already seeing that.

And, Wendy, I was so disappointed and so disturbed to see that Pelton & Crane announced yesterday that they are closing. No chapter 11. No chapter 7. No acquired at a discount by some other company. They're just closing. 100 years they've been in business and built a very good product, have a very good reputation. It just stuns me that a company of that size, of that complexity, of that history, and of that strength, is going out of business.

It is super sad. And they're not the only ones, right? We see a lot of news reports about local businesses. I saw a gentleman the other day featured on some news program that had been in business for 38 years. And he was sobbing at the fact that he had to now close his restaurant and his life's work has gone away. And we're seeing even other big recognizable names, J.C. Penney, Pier 1 Imports, even Kohl's department stores are in trouble. So sadly, I think that we will see quite a few jobs that won't return and we need to be prepared for that.

That's for sure. And so we tried to find a number and this is from Forbes. And that this writer is suggesting 42% of jobs lost aren't coming back. I hope that's not the number. I hope that's an exaggeration. I hope we're far lower than that. But if you take-- I think we're up to - what? - 38 million now unemployed. If 40% of those jobs don't come back, it's going to be a very long slog for our economy to recover from that. So my hope is that this is an exaggeration. But Forbes is really not known for exaggerating. It's usually a fairly solid source for information. Here's what's happening in dentistry. So these numbers are one-week-old and this is from our friends at Dell Intel.

This is the combined production from all the practices in their system. And so we can see that it's bumping back up in our client base. Most of our clients' practices are open, most of them are very busy. In our own practices, we're to our pre-COVID level and slightly higher, actually, than our pre-COVID level. So practices are starting up very, very strong and I'm delighted to hear that. And so, Wendy, one of the things that we've been talking about and we've created an experience for people to get ready for this, are our 100 day COVID recovery plan. And our thing was, there's going to be a lot of pent-up demand. Let's just go after it. Let's be ready, let's open up, let's get started, let's take care of patients. So as we do that, we're going to see the demo numbers go up. But if 42% of those people's jobs are gone, we're going to see it go right back down again and so we've got to be prepared for that.

Right. And there's still so many changes, right? So that's the thing that we want to talk about next, is there's a lot of churn, there's a lot of uncertainty still, there's a lot of the cloudiness about how we should be operating that still exists. So for our big three, for this video, we thought we'd discuss a few of the questions that we're still hearing, some of the challenges, the concerns, that people are hearing, and of course here we have the CDC, they launched new guidelines for dental practices. The guideline that caused so much conflict between dentists and hygienists, thank heavens has been removed. The recommendation for all elective procedures to be postponed, that was changed as of May 18th. So we're happy about that because, again, that directive from the CDC was in direct conflict with what many of the governors had decided, and what the state boards had decided. So now that's at least helpful, to not have that conflict.

And I've been picking on the CDC since this whole thing started, and I have to say, good job here. You corrected something that was clearly-- you gave evidence in your first guidelines of why those guidelines didn't make sense. But you still went with the guidelines of urgent and emergency care only. So good job for becoming more informed, understanding dentistry, understanding infection spread in dental offices, understanding the PPE that dentists wear. Good job for going back and changing something that you decided. It's hard to do do that when you're in a political position and the spotlight's on you, and good job to CDC.

Yeah. Delighted for that. Another change for this week, which when I first read this, to be honest, my first response was, "You have got to be kidding me," because this thinking that coronavirus spreads easily on surfaces had people disinfecting their groceries. When Amazon boxes would be delivered on the front door, people had to disinfect those, and just this craziness that this thinking, I guess, inspired in our society was a little over the top. And now they're saying, "Oh sorry, guys. Coronavirus does not spread easily via surfaces."

So it sounds like that guy didn't have to disinfect his groceries on TV to show everyone how to properly do it [laughter]?

Yeah. You just have to shake your heads. And I get it. We are trying to kind of learn about this virus in real time and that's got to be a super challenging thing to do but some of these changes, I think that's part of why there's so much frustration still amongst members of our profession because we don't know what's right. What's true today may not be true tomorrow. And so it could be really frustrating to try and determine okay, what's our plan of action? So let's kind of review where we are with the state of hygiene and doctors. This was posted not too long ago basically saying went in for a meeting, came home, and cried. I hate this new normal. And we're seeing all sorts of things.

This is actually one of our clients and this image on social media, and so this is our new normal today. We're getting questions about what kind of respiratory protection systems do we need. This is a real thing. There are people actually outputting themselves in things like this to actually take care of patients. And we're seeing trouble with people not being able to breathe in their N-95s. Practicing using close oximeters to make sure that we're safe. There's a lot of angsts given where we are, which is completely understandable.

Oh yes. I saw this and I had to chuckle, right? Just like that, having a mask, rubber gloves, ducktape, plastic sheeting, and rope in your trunk is okay, right? So this is kind of the state of where we are in our society. And if you can't laugh, then I guess you're crying, right? I mean, that's what they say. So we see general public wearing a mask everywhere we go, and for us, it would have been trained in proper PPE protocol. It's a little frustrating because you've got people touching their face excessively. I would say expert opinion is still split 50/50. I just read a news article yesterday that said hey guys, wearing a mask if you're not going to do it right is not a good thing. So it's just kind of an interesting time.

Yeah. And these are the people that we look to for answers, and so it could be frustrating. So here's one of the questions we're getting. So we cover top three questions. Here's one of the top that we still get even with all the resources we've put out there on disinfecting and all that. So I thought it would be good to just revisit this question. What do we know today? The question really is about disinfecting the rooms, how much time should the room be empty between patients, and again, what products are best to use. Is there anything new that might be worth looking at when it comes to disinfection?

So with that, I did some research. We did some research. We had one of our members ask us a specific question about a type of disinfectant that they've been reading about. So we thought it would be good to share. This is published in the British Dental Journal in April of 2018 about nature's own powerful non-toxic disinfectant. And what they're talking about is hypochlorous acid. And don't let the name scare you. I first thought hypochlorous acid, that does not sound good. It sounds like it's going to eat right through our chairs and all of the surfaces in our practice, probably destroy our equipment, and we don't want that, right? So what is it? So we have to take care of what we have, right?

Right. And instantly, we've got people of [inaudible] looking for parts, right? So we don't want to go down that path. So hypochlorous acid is actually an acid with a low Ph value, kind of like a mild citrus juice. And it is proven to be a powerful [inaudible] that kills fungus, bacteria, and viruses. And so we're seeing more and more people using hypochlorous acid in health care, in water treatment, for food safety, general sanitation because it's not harmful and it's a good disinfectant. So I dug in and did some research, and interestingly enough, a lot of cruise ships have begun to use this as a treatment more readily. So they're using it as sanitation, heavy-duty chemical disinfectants, but there's also a better safer way. So really what is hypochlorous acid? It's electrolyzed water. So it's a fairly simple thing to make. You can actually make it in your office and there's a whole host of companies that do that.

But interestingly, if I wanted to highlight that in this article it talked about in hotel areas of the ship, the acid is actually better than bleach and peroxide-based chemicals because it doesn't cause discoloration of carpets, furniture, and textiles, which is really important for us to know, right? So I thought this was worth at least mentioning. It's also very, very safe. It's not irritating and we can inhale it without problems as well because that's a concern of a lot of people as well is, "Oh my gosh, we're spraying the room with all these harsh disinfectants and chemicals. How could this be for us to actually be breathing that?"

So another thing that was interesting in this article is that it's unusually efficient in eliminating viruses. And one of the big reasons people are switching over is efficacy. So they did research proving that electronically generated hypochlorous acid can kill neuro virus in less than one minute at a relatively low parts per million ratio. So this is super good news for us and particularly because it's also been proven to work well against viruses and human coronaviruses.

So there's a study done in 2016 at the University of Washington School of Public Health, and they found the hypochlorous acid was more than 99.999% effective in eliminating coronavirus OC43 which is very similar to COVID-19. So all this is really great information for us, and this is not a new product in regards to dental disinfection. It's actually been used for several years. A lot of people have been using it to disinfect our water lines because it isn't harsh, t won't destroy the water lines. But you can see here, this was the published efficacy regards to minimizing the colonization of microbes in the waterline. So this might be something for you to explore. Again, it works fairly easy in my basic research. Certainly, we are not experts on this technique. We are not experts in disinfection at all really. If you want the list of the approved Gordon Christiansen disinfectants you can easily access that at cliniciansreport.org. And you go to the bottom and he has a list ranking all of these actual disinfectants. This is a little bit different because you can make this electrolyzed water in your office.

So it's a fairly easy thing to do. It takes about eight minutes. You use table salt, distilled vinegar, and water. And then you could actually take this solution after it's formed it makes 200 parts per million of hypochlorous acid right there in the treatment room. And you can convert it into a fogger, or a spray bottle, or whatever your preferred delivery mechanism might be. For those that are worried about how long particles are staying in the air, if you're spraying this in the air, fogging it in the air, the thinking is that there's no longer a need to wait for those particles to settle. Okay?

So if you want more information about this go to infection control tips. And there's a lot of information there about hypochlorous acid. And certainly, you can do what I did and use the Google, right, and Google up any research studies about utilizing hypochlorous acid in disinfection and dentistry. And you'll find a lot of compelling articles to do your own research. So it's an option. Although, remember we started this whole crazy talk by the key shift CDC officials now saying the coronavirus does not spread easily via surfaces. So to each their own. Right? We've talked with some practices in New Jersey and New York where there's still a very high level of fear. And this may be yet another strategy to minimize that fear and show your patients and your teams what you're doing to keep them safe.

That's right.

So as we go, the next question, should I be dropping insurance plans right now? One of our posts on social media, as well as a client, sent in a question that said, "I really don't think I can't afford the write-offs at this moment." And so that's interesting. We've seen a few posts that were a little alarming. Right? So this is a doctor that posted on a dental page. "Finally dropped Delta. I'm officially 100% fee for service. Control your own destiny. Set your own fees. Be free. Insurances don't get you ahead, they hold you back."

Yeah. And I think this is an interesting mindset. So the question about whether or not to take insurances or not take insurance really has to do with your practice strategy. Right? What is your long-term goals? What is it that you're trying to accomplish? It has nothing to do with COVID. It has nothing to do whether you can afford the write-offs. So our good friend, Heather Driskill, always said, "Well, would you rather get 75% of something or 100% of nothing"? Because patients do tend to largely go where their insurances accept it. And so these practices that are deciding to do this right now may be killing some patient demand. And I would be cautious about that.

Unless you're in a very highly, over demanded situation, you're booked way, you don't have enough capacity, you don't want to build on capacity. If you're booked out with good, restorative cases four or five months then maybe this makes sense to do this. And, of course, if 45% of the people who are unemployed don't have jobs back they're not going to have dental insurance. Right? So if you're in that kind of situation situation, then, yeah, I think that probably makes sense to start dialing some back, right. So you pick some, you drop those, and you see what happens to your patient numbers. But to decide at this time to do something that's going to interfere with patient demand is really a risky strategy. Right. And so, we really want to be cautious about that. Anything else you want to say about that, Wendy?

Well, yeah, I mean, they're not the only ones, right? Because we're seeing a multitude of people on social media really kind of, excuse me, talking about-- we talked about how dangerous groupthink can be. Just because it's common doesn't mean it's smart. Right. So here's another post. Now is a great time to make changes while everything else is up in the air too. I've never been an insurance practice, but I can't see how anyone can now take 25 to 30% lower fee and still cover the overhead which is just increased. Go full fee and spend some money on targeted marketing. Well, we've seen practices embrace this strategy to their detriment. I'm not saying that it never works. There certainly are. We work with some great fee for service practices.

However, in this moment, when there is you that's what you're saying it's going to be a W-shaped recovery. Right? So we had a significant drop, then we're going to see a ramp back up as we covered demand. But there are experts are saying that we're going to see another decline and where do you want to be in that decline? Do you want to be hungry for patients and depending on marketing, attracting new patients to your practice? Or do you want to be doing same-day dentistry and being smart to harness the principle of the next dollar to maximize the impact of the patients you already have? So, again, we're not saying that this is necessarily a bad strategy, but just because everybody else is doing it doesn't make it the right strategy for you.

Right, and it's not a bad strategy for some, but probably for many-- most probably most, this is not good timing, doing it suddenly is going to be very, very harmful, very difficult to recover. And so if we look back at what happened to practices in the previous economic downturns, we'll talk about here in a little bit, you'll see that this may not be a strategy that makes a lot of sense for most practices.

Right. So that really is-- what about the feeling that I can't afford the write-offs? I mean, you kind of addressed it with Heather's statement, but what else would you say on that?

Well, everyone would rather not have the write-offs. That's a universal, nobody wants them. But the trade-off is that you have patient flow. So you're taking a little less fee, but you're having more patient flow. Now if you're one of those people who has a demonstrated record of generating patient flow, even without insurance, go for it. Right But if you're not, and in one of the previous slides you had, Wendy, the person was saying, "I'm just going to do more targeted marketing." Well, yeah, that's fine. But we'll see if you can replace the demand in it very, very down economy.

So we're going to see and I've been through this in my career and I know what it's like when people don't have jobs and they don't have any money to spend. I've lived through this once, so I know what it's like and I know how bad it can get and I know how bad it's going to get. Now, hopefully, it's not going to last that long. Hopefully the Federal Reserve Chairman was saying probably 18 months it'll start to normalize. So, but 18 months can be a long time particularly practices, those individuals that are in high debt situations, it's a long time.

Absolutely. Well, but let's move on to the next this question is the last question, "What is the best way to restart hygiene in my practice? Do you recommend I go from zero to a hundred percent right away or gradually over time?" Now, this is one of the things we talked about it even at our very earliest Facebook live updates, is how important it is to have your hygiene strategy dialed in now. And now, with the majority of our practices being open, Dr. Martin from the UK - hi, Dr. Martin - he posted in the comments that they're still not open in the UK and no sign of a date forthcoming from leadership to reopen.

So there are some states, some countries that are still struggling without opening at all. And now is the time, Dr. Martin, now's the time for all of these practices to really dial in to your strategy. And we are seeing some practices making some horrible decisions in this area and also still struggling with having hygienists and team members wanting to come back to work. So in our country, in our effort to make things better, there were a few decisions made that I think has made it harder for us to get our teams to come back, right? Here's a restaurant from Times Square. They said that they have more than 30 job openings with very few applications because the employees are furloughed and they're making more money from unemployment than they do actually working. And we're starting to see that happen in some aspects in dentistry. Here's the Home Depot co-founder. He said, "The media has done a wonderful job of frightening America." We talked about that on our updates as well.

Home Depot, one of the companies that is doing absolutely fantastic right now, their sales are way up, their profitability is up because so many people with nothing to do were taking care of those projects that they put off. And so I know our Home Depot down the street from our house is super busy. But he's right, we've done a wonderful job of frightening people.

Right. And another thing that's an unintended consequence that a lot of people are trying to figure out, a lot of states have varying rules and regulations here, is practices are unclear on what really applies to them. Mnuchin said, "Employees who reject offers to return to work are ineligible for unemployment benefits," and that may take some time, as we talked about earlier, to catch back up. But this is part of our harsh reality. So here's a practice, and this was what they decided to do about hygiene in their practices. So I read this and I just could not believe it. They are canceling the patients who were scheduled right now, canceling everybody, and telling them that they have to give the previously scheduled patients a chance first.

So they're giving them an option to be on a short call list if there's a last-minute change. I could not believe what I was reading when I was reading this. Again, Dr. John, this is just proof as to why some of these questions have got to be-- you got to be working on this before you open. And now that you are open, what are you doing to address this pent up demand? And making sure your strategy's dialed in, it's well-communicated to the team is so critically important to your success.

And not only is it a bad strategy to call and cancel patients, but they're doing it so poorly that half are opting not to come in [laughter]. So the ones that are rescheduling, half of them were saying, "No, I don't want to reschedule." I mean, can you imagine what's going to happen to this practice? I mean, it's going to [inaudible].

It's so sad.

It is, it's really sad. That practice is going to take-- it's going to take them years to recover from this experience. That's why we came up with our 100-day checklist, which was helping people think through what are the questions you need to answer. And because we have so many people who said, "Gosh, we'd like a little more help working through this 100-day checklist," we put together our 100-day recovery plan program. And it's to help people prevent from making mistakes like that. I know, it sounds good, and there's a certain kind of fairness or something in there that they're trying to achieve. But they're absolutely going to just just kill their practice. It's really sad.

Really sad. So the best way to restart hygiene in your practice, it is to download our 100-day checklist. Think through those questions. Have a plan in place. Our coaches did a session on Facebook Live a few weeks ago on hygiene blitz days. That's how a lot of practices are addressing their demand that have backed up. Now, it's somewhat problematic initially, because we're hearing from practices that they are adding a little bit more time to their hygiene appointments, in case there's a need for enhanced sterilization. But it's not much. It's, maybe, a 10-minute window.

So some of those things you'll figure out as you begin serving patients, but the strategy, the communication, all of that, is super important at the very beginning. So if you've been open for a week or if you're opening in the next few weeks or if you're still waiting for your open reopen date, make sure you have this strategy dialed-in. Because we always say, come back as close to 100% as you can, especially on the hygiene side, because the pent-up demand will get you through any coming economic downturn that may happen. So this is such an important thing to have dialed-in.

There's another serious cash crunch coming. So you've got to be ready. And if you can take advantage of the pent-up demand right now, that'll help you recover some of your working capital that you probably spent off and give you a chance to survive the next cash crunch when it comes.

Yeah. Super important. So for those of you that are listening, that have not downloaded the checklist, you can go to 100daychecklist.com and download that. And then we'll share with you a few minutes from now-- and we'll put that in the comments, but we'll share with you in just a few minutes some of the other ways that we've helped practices actually implement and utilize that checklist. So Dr. John, you mentioned just a minute ago about how you've lived through past economic downturns. So let's kind of end today's live update with some things that you've learned, that we've learned from past downturns in our country.

Sure. So I graduated from dental school in 1986 and started a practice in Onawa, Iowa. So agricultural area, and it was the depth of the farm depression. And the unemployment rate in the city that I was in, the small town, it certainly exceeded 25%. It certainly was higher than that. And the farmers were-- the commodity prices collapsed. They had crops in the ground, but they couldn't harvest them and sell them for more than it would cost for them to harvest it because the commodity prices collapsed. So farms went bankrupt. This was the tipping point where we started to go into the corporate farms when the family farms died off. The local banks all failed. It was a really, really horrible, horrible time. And so I've lived through this. I know what this looks like.

And you don't think it's coming, you think you're going to be fine, and you think you're going to be okay. We've had such a great economy for the last 10 years that it's hard to imagine how bad it can get. So here's some of the things that we saw during the economic downturn. Number one, new patient numbers go down, and the cost of acquisition-- so if you're marketing to generate new patients, the cost of acquisition goes up significantly, double or triple. So it goes up a lot. So if your strategy is to chase off some of the patients you have now and replace them with new patients, remember, it's going to become-- because there are fewer and fewer people looking for dental care, it's going to become more and more expensive to compete with everybody else who's marketing for new patients. And you're going to have to spend more and more to get them. All right.

Next thing, Wendy. Remember that some patients are unaffected financially, right? So we can't treat everybody as though they don't have any money. We can't change our diagnostic standards because we think no-one has money. We can't change how we offer all kinds of opportunities for patients to get their care because they are some people, they're going to cruise on just like they always have. So we have to be cautious because we can get caught in that mindset that no-one has money and everybody's out of work and all of that. We will see that most patients become much more insurance-driven when they are-- if you consider the typical American family, if 45% of the current unemployed don't go back to work, that means in a family of two working parents, one of them is going to be out of work. Well, when that happens there's less disposable income, and when there's less disposable income, people are going to be more insurance-driven than ever.

What's interesting, Dr. John, is sometimes we make assumptions, right? So because some patients are more insurance-driven, we often withhold. Like you said, it affects our diagnostic assertiveness. But we also, on the hygiene side-- I have seen hygienists that are reluctant to offer preventive services that mean an out-of-pocket investment. However, one of the things that I learned on the last economic downturn is that because they were more financially strapped, they became more interested in prevention because they wanted the longer-term minimization of dental problems. And so they became even hyper-focused on preventive services. So be careful that you don't withhold those opportunities because we found patients were still very interested. In fact, some patients were more interested in prevention because of their economic situation.

Yeah, good point, Wendy. Next is patients are often less interested in payment plans. And the reason is they've already got debt that's piling up. They're living off their credit cards and they have more and more debt piling up. So coming up with-- making sure that your team understands how we're going to do case acceptance, how we're going to help patients get-- how we're going to get paid for the treatment that we do. How we're going to help patients get the care that they need. The strategy that you've used in the past is not going to be as effective now so you've got to adapt.

Treatment acceptance declines and so in-- we know that elective care tanked during the financial crisis, right? So that was 2008, 2009. Elective care tanked. A lot of private practices that were elective care only, which was kind of a thing at that time, a lot of those went bankrupt, went out. I mean, gone. Here in Phoenix where I live, there were 500 practices, almost 20% of the dental practices here, closed during those years. And most of them-- ones that were hit the hardest, were the ones that were elective-focused practices, cosmetic type practices. So treatment acceptance is going to decline.

But remember always low case acceptance isn't only about the money. It's about trust, it's about clarity. It's about people understanding, right? So we can improve our case acceptance process enough to make up for some of these treatment acceptance declines. But it takes a certain skill-set, it takes a certain knowledge-base, it takes a certain team-work in order to make that happen. And so that's one of the things that we can do something about. Some of these things are going to happen and there's nothing we can do about them but that's one of them we can certainly do something about.

And we generally see revenue drops during the recession-- dentistry as a whole. During the last financial crisis, the dentistry as a whole was not affected that much. We stayed within 3% of the high for a couple of years there and then it started to take off again. So we were not very affected by the last financial crisis and I hope and pray that we're not as affected by this one. But this is going to be a much sharper, deeper financial bump than what we experienced then. So hopefully, we will come through fairly well. I know those practices that prepare, those people that have the systems in place, and the strategies in place are going to have the best chance to be coming out of this with the fewest scrapes and bumps and bruises and bankruptcies, right?

Right. So again, we have missed doing some of these updates but we've been so busy creating our eight modules for our dental practice recovery plan and guiding practices through that. If you'd like more information on that, if you'd like to find out more about that-- really what that is, is that 108 check-list. We go step-by-step through how to prepare and how to come back stronger than ever. And those practices that are already opened again, how to really make sure you're maximizing the opportunities that exist as patients start coming back to your practices. So again, those that aren't open yet, hang on. Our hearts are with you. We've said from the very beginning, this too shall pass. And hopefully there's a light at the end of the tunnel as we're seeing more and more states and more and more areas opening up again for elective dentistry. We're super happy to see that.

That's for sure. Well, thanks everybody for joining us on our Facebook live. Wendy, it was great to be with you. And hang in there everybody. We'll get through this.

Enjoy your Memorial Day weekend.

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