A dentist in Chicago I met through LinkedIn reached out to me in July. He has a two doctor general practice with five operatories. They collected $2.7 million in 2025, and their 2026 schedule has been the fullest since he bought the practice. New patients had a four week waitlist. He wasn’t a client, but asked my opinion on adding a sixth operatory.
My first question was for their year-to-date numbers. I’m never surprised anymore when it comes to numbers. It was almost expected that I would find the collections were only up .9%.
His preplanned explanation came next. The waitlist showed demand, and the flat collections were a posting problem. He said somebody in the front office must be falling behind on payments. Once again, the explanation he gave was expected. I’ve heard it before. Chalk it up to 30 years’ experience or one of my many personality defects. I quit trying to figure out the difference years ago.
The schedule is real. The story about it is wrong.
A full book does measure something. It’s just not what he thought.
The fee schedule, like almost all fee schedules in general dentistry, is mostly dictated by the plans they participate in. Those plans have been paying less in real terms every year for five years. The ADA’s Health Policy Institute puts the reimbursement rate index up 19% since January 2021. General inflation over that same stretch ran 27%. In 2026 alone, January through June, reimbursement moved 1.1% while inflation was 1.8%.
Look at it this way: when a price falls in real time for five years, the chairs are filling with the work that price underprices. The patients are doing the sorting, which means they are keeping the cleaning and the exam. The emergency gets seen because it’s an emergency and it has to. But the restorative work is getting pushed to next quarter, and the implant is getting pushed out a year until the household feels better about the money. The schedule is getting filled with visits, and each visit is carrying less. (Hopefully that came out right. My voice-to-text method receives much less refinement since someone flagged me for AI slop on LinkedIn. That’s another essay.)
Now you and he know what the schedule was actually measuring. A queue forms at a price that’s too low for the mix. He was reading rationing as growth.
One practice, two years
Treat the practice below as a composite, built from the shape I keep seeing. The numbers are rounded so the math can be checked on a napkin. 5 operatories, 8 hours per day, 4 ½ days per week, 48 weeks per year.
Operatory hours, both years = 5 x 8 x 4.5 x 48 = 8640
Last year:
Hygiene and exam visits = 6,000 at $190 realized = $1,140,000
Restorative visits = 3,000 at $520 realized = $1,560,000
Collections = $2,700,000 Visits = 9,000
This year:
Hygiene and exam visits = 6,800 at $192 realized = $1,305,600
Restorative visits = 2,700 at $525 realized = $1,417,500
Collections = $2,723,100 Visits = 9,500
Visits up 5.6%. Collections up 0.9%. 500 more people came through the door, the wait list got longer, and the money barely moved. That’s what was actually being presented.
Now take the collections change apart. Only three things can move it, and one of them is doing most of the work here.
Volume effect = 500 more visits × $300 last-year average = +$150,000
Mix effect = (6,800 × $190 + 2,700 × $520) − (9,500 × $300) = −$154,000
Price effect = $2,723,100 − $2,696,000 = +$27,100 Net = +$23,100
The .9% he trusted is a $150,000 gain and a $154,000 loss standing on top of each other. The practice grew and shrank in the same year, and the P&L netted the two into a rounding error.
Then run contribution, with the hygienist raise in it, because he gave one this year and so did everybody else.
Hygiene contribution per hour, last year = $190 − $60 − $10 = $120
Hygiene contribution per hour, this year = $192 − $62 − $10 = $120
Restorative contribution per hour, last year = $520 − $30 − $110 = $380
Restorative contribution per hour, this year = $525 − $31 − $112 = $382
Total contribution, last year = 6,000 × $120 + 3,000 × $380 = $1,860,000
Total contribution, this year = 6,800 × $120 + 2,700 × $382 = $1,847,400
Contribution per operatory hour, last year = $1,860,000 / 8,640 = $215
Contribution per operatory hour, this year = $1,847,400 / 8,640 = $214
Same practice. 500 more visits. $1 less per hour the chairs were occupied. See how he’s working harder for the same money? And the schedule that told him things were going well is the reason.
Why the chairs filled with the wrong work
Two forces did this, and a third explains why he couldn’t see it.
The first is the price. A fee schedule that lags cost for five years stops sorting. Above a clearing price, a practice chooses its work. Below it, the patients choose the cheap visit. HPI’s own report has the second most common reason pessimistic dentists give for their outlook as patients unwilling or unable to prioritize care. That’s what’s called mix moving.
The second is that the fixed hour got more expensive while the fee for filling it didn’t move. The hygienist raise is in the math above. It took $2 per visit off the hygiene contribution, the fee gave back $2, and the department came out flat while looking busier than ever.
The third is the reporting, and this is the one that keeps the other two from being seen. Practice management software reports production and collections as totals because that’s what comp gets paid on. Nobody in the practice gets paid to look at contribution by procedure class per occupied chair hour, so nobody does. The number that would have flagged the mix shift in March is the number none of his reports produce. (If you follow my work, you’ll recognize the metrics. Contribution per owner hour after collections per matter, contribution by procedure class per occupied chair hour.)
The number the software won’t print
Contribution per occupied chair hour, by procedure class, monthly. I’ve defined it here so you can run it yourself:
Contribution per occupied chair hour = (collections − provider and hygienist labor − assistant labor − supplies and lab, by procedure class) / occupied chair hours
Occupied, not scheduled. Hygiene against restorative against elective. Run it by class, and the schedule template turns into a P&L, because every hour you allocate to one class is an hour you took from another at a known difference in contribution. (More Sheets language.)
Pair it with the decomposition above, and run monthly. Volume, mix, price. The mix line is the early warning. It goes negative months before collections notice.
The sixth operatory was the wrong question
He appeared in my DM’s asking the wrong thing. The question I answered was what the fifth operatory produces per hour today, by class, and what a scheduling rule that moves hours between classes would do to contribution before it goes flat.
Let’s look at the levers here. At a fee schedule he doesn’t control, the lever he does control is the template. Which hours go to which class of work. Behind it sits case acceptance on plans above a dollar threshold, and further back, the question of which plans he keeps at all. Each of those is a rule, and a rule holds (think: a governed decision system) when a front desk, under pressure, would otherwise book whatever fits. RIDA (the economic discipline I created) runs the decomposition first and writes the rule second.
There’s a transaction version of this, and it is worth mentioning here. The CIM, if he ever writes one, will say fully booked with a waitlist, because it’s the truth and it sounds like demand. The buyer’s operating partner will run contribution per occupied chair hour on the second day of diligence and then price the growth story.
A seller who ran it first has an answer.
This essay describes general transaction structure. It is general in nature and does not constitute legal advice, a valuation, or investment advice. Figures drawn from published sources are attributed in the text; the two-year figures are illustrative composites and describe no identifiable practice.
Sources. ADA Health Policy Institute, The State of the U.S. Dental Economy, Q2 2026 (July 2026): reimbursement rate index up 19 percent since January 2021 against 27 percent general inflation; January through June 2026 reimbursement up 1.1 percent against 1.8 percent inflation; share of dentists reporting not busy enough at 26 percent, down from 33 percent in Q4 2025; average new-patient wait 13.9 days; 589 responses, 552 in private practice, owner-skewed. U.S. Bureau of Economic Analysis: real consumer spending on dental services up 1 percent over the twelve months to May 2026. The two-year practice above is a composite; figures are rounded and illustrative.