Ep. 229: The New Rules of Dental Staffing (Whether You Like Them or Not)
What worked for hiring and managing staff a few years ago is no longer enough. Jeff and Ashley break down the modern realities of dental staffing from payroll pressures, shifting expectations, and making smarter hiring decisions.
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Cedr Solutions - https://www.cedrsolutions.com/
Smile Care Claims - https://www.smilecareclaims.com/
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Questions From This Episode
What's the domino effect Ashley describes with rising wages, and why does it hurt practices that try to ignore it?
Once a practice raises pay to actually hire a new front desk person or assistant, existing longer tenured staff who are earning less start noticing and asking for raises too, or simply leave for a competitor down the street paying more. Practices that respond by not replacing lost staff, or trying to replace an entry level role like reception with an AI phone system, end up losing new patients, cutting hygiene, and producing less, which shrinks the practice further instead of solving the actual problem.
Why doesn't Ashley think AI is actually a workable replacement for a receptionist right now, even though the technology sounds convincing?
AI functions as a force multiplier, helping a person do their job better, not as a true replacement, and a caller who reaches a machine instead of a live person during business hours is far more likely to simply move on to the next practice on Google. Mystery calls into newer client offices have caught this happening in real time, an automated system answering mid-day, which quietly wastes every dollar spent generating that call in the first place.
What does an HR company actually do, and why does Ashley compare having one to having an accountant?
An HR company's core purpose is compliance, keeping employee manuals, hiring policies, and practices aligned with constantly shifting state level labor laws around things like sick pay, breaks, and background checks, which now vary so much by state that a doctor genuinely can't keep up without outside help. Just as almost every practice already has an accountant, having an HR company has become an equally standard cost of doing business, typically running from the mid hundreds to low thousands of dollars a month depending on staff size and services.
How has the actual hiring and onboarding process at MGE changed to adapt to this environment?
What used to be a multi day process, a second interview, then an offer a few days later, is now often compressed into a single day, background and reference checks included, since strong candidates simply won't wait around. Onboarding has also expanded from about one day to up to three, with more time spent up front making sure a new hire genuinely understands how the whole organization fits together, since building someone into a fully capable office manager now has to happen in three to six months instead of the two years it used to take.
What's the single biggest mistake Ashley sees newer clients making with personnel, and what's the actual fix?
Understaffing, and then trying to cope with it by outsourcing core patient facing roles, having the doctor personally cover hygiene, or holding onto an employee who genuinely isn't performing simply to avoid the cost and effort of finding someone better. The real fix isn't cutting staff, it's the opposite, hiring enough people to actually bring in and treat more patients, since that's what grows the revenue needed to support a properly staffed team in the first place.
Episode Transcript
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Jeff: Let's talk about something we all sort of know from lived experience, you'd have to be living under a rock for the past six years to not have noticed that staffing your practice, or any business for that matter, seems more complicated and expensive than it did back in, say, 2019. And to that end, building and managing a team seems harder than it used to be too. Does it feel like expectations are fuzzier, standards are harder to hold, and what used to work just doesn't anymore?
Jeff: If your practice is fully staffed, turnover is low, and your team is genuinely dialed in, great, well done, seriously, you're ahead of the curve. But if you're like the vast majority of your colleagues, where staffing in one form or another is an ongoing issue, this episode is for you. Because here's the truth, this isn't necessarily a you problem, and it's not necessarily a bad employee problem, it could be, but for the most part, if this didn't used to be a big problem and now it is, there are a few things worth knowing. The labor environment has changed over the past six years, the workforce itself has changed to one degree or another, and most practice owners and office managers were never prepared for this version of reality. What used to be common sense in staffing now might get real pushback. What used to simply be expected now has to be negotiated. And a lot of owners are stuck trying to run a modern practice using rules that quietly stopped working years ago.
Jeff: That's the why behind this week's episode. My name is Jeff Blumberg, and I'm your host, and this week we're taking a deep dive into the new rules of dental staffing as they've evolved over the past six years, specifically what's actually happening inside dental practices, and what owners and managers need to adapt in order to succeed in this current environment. To help with this, I'm joined by Ashley Fuegel. If you're a longtime listener, you'll know Ashley from several previous episodes on personnel. Ashley is our VP of Administration here at MGE, essentially our resident HR expert, though I should qualify that, she's not an employment or labor attorney, this is important, you should have access to one of those, so nothing we're discussing here is legal advice. Ashley's been with the company for 20 years now, and she's genuinely excellent at this. Beyond overseeing MGE's own personnel area, she's worked directly with hundreds of our clients on staffing issues. Ashley, welcome back to the show.
Ashley: Thank you, glad to be here.
Jeff: So we've got a series of questions today, and full disclosure, Ashley's already seen them, I didn't want to spring a surprise interview on her. Let's start here: when you look at hiring, onboarding, and staff training today versus a few years ago, what's fundamentally different?
Ashley: I'd break that into two pieces, hiring and onboarding. On the hiring side, the biggest thing I see is cost. Everyone already knows costs are up across the board, but the real effect has been more of a domino effect. It started simply enough, it got more expensive to hire a front desk person, a dental assistant, a hygienist, and clients adjusted, they started paying more for those roles. But then existing, longer tenured employees start noticing. They see the new hiring ads and think, wait, you're hiring a dental assistant for $25 an hour, and I'm only making $23, or $20, because I've been here a long time. That worked fine back in 2018 or 2019, when new hires and existing staff were being paid roughly the same. Now that gap creates real pressure, existing employees want more money too, or they'll simply go work for the practice down the street paying more.
Jeff: So how have you seen practices actually respond to that pressure?
Ashley: In a lot of cases, not well, and it ends up genuinely harming the business. They lose a staff member and don't replace them, because they've decided they can't afford to, or they try replacing that role with AI instead. We see this constantly now, our sales team runs mystery calls into prospective client offices, and increasingly a machine answers the phone in the middle of the business day. They're treating reception as an entry level role they can hand off to a bot, so it can handle basic questions and free up an existing employee to step away from whatever they're doing to occasionally answer the phone.
Jeff: I've told our own clients, and I know you've said the same thing, your receptionist is genuinely gold, they're the entry point into your entire business. You spend real money on marketing, and then no one actually answers the phone, just a machine.
Ashley: Right, and think about it from the caller's side. If a machine picks up and says thank you for calling, whoever, I'm hanging up. Unless I'm already a referral, my spouse sees this doctor, there's no real reason for me to chase it down if I just found the practice through a Google search or ChatGPT, I'll simply move to the next listing.
Jeff: That's exactly right. I actually have Dan on the show in a couple weeks specifically about where AI stands right now for helping a practice, and without giving too much away, one of the fundamental issues is that AI is really a force multiplier, not a replacement. It's like wearing a robot suit that helps you lift a weight better, it doesn't lift the weight for you. Some companies are building convincing voice AI receptionists now, and it genuinely is remarkable what's possible, but we're not at the point where it can actually replace a person for handling live calls.
Ashley: And it doesn't really solve the problem either. Even in a best case where it sounds convincingly human, it might take a message, someone left their glasses, we'll call you back, but that doesn't save any real time, it just makes the caller feel like the phone was technically answered. Meanwhile you're spending real money on pay-per-click leads or an implant funnel, and that lead just evaporates.
Jeff: AI genuinely does have real uses, helping evaluate x-rays, for instance, or handling after-hours coverage might be a reasonable use case.
Ashley: Sure, after hours might be fine. I'm specifically talking about the middle of the business day. And when practices skimp on having an actual person at the front desk, they get fewer new patients, and they make less money as a result. I'm also seeing more clients coming in with no hygienist at all, or worse, the doctor doing their own hygiene.
Jeff: Really, no hygienist at all?
Ashley: Genuinely, ask our Power Client Managers, they're seeing this from newer clients regularly. I'll ask them directly, how are you running a dental practice with no hygienist, and it's often because the doctor is covering hygiene themselves on certain days. So production drops, since now they're personally doing hygiene instead of higher value work, revenue shrinks, and they can't afford payroll, so they shrink further. It becomes a genuine vicious cycle, all stemming from that original wage pressure and not adjusting to it intelligently.
Ashley: To be fair, some outsourcing decisions are genuinely smart. A lot of our clients are outsourcing insurance filing now, and that works well most of the time, it's a genuinely intelligent move, since you can take an experienced employee who understands dentistry and repurpose them into a role like office manager or scheduler instead, earning more while the insurance work itself gets outsourced for less.
Jeff: Worth mentioning, we work with a company that handles insurance filing specifically, Sabri actually came on the show and talked about it a while back, it's called Smile Care Claims, I'll put a link on the episode webpage. And since you brought up AI, I get asked constantly whether AI could eventually handle insurance filing entirely. There are AI tools now that help on the front end, generating and submitting claims. But here's my prediction: we already have the technology to let AI run the entire process on both the filing and paying side, if insurance companies wanted to build a system where AI evaluates x-rays and narratives instantly and pays out in 24 hours, they could. It will never happen, because the insurer benefits from sitting on that money as long as possible. You might see genuinely good tools on the practice side, evaluating a claim before it goes out, helping with benefit verification, but you're never going to see meaningful automation on the follow-up side, because that delay works in the insurance company's favor.
Jeff: So, back to onboarding specifically, what's changed there?
Ashley: The biggest shift is the sheer number of new rules around how you're required to handle employees, sick pay, break requirements, and a growing number of states now requiring employers to cover a portion of disability coverage and similar benefits. And clients simply don't know what they don't know. It's not the same environment it used to be. You used to be able to get by knowing how to hire good people and train them reasonably well. Now the compliance side has changed so much that you can't just hope you'll figure it out, or rely on a friend who happens to be an attorney for occasional advice, or read through your Chamber of Commerce's general tips. It's changing too fast, and employees are increasingly aware of these changes themselves. We already advise our existing clients on this, but new clients coming in typically have no system in place at all. We tell them plainly, you need an HR company. It's become exactly like having an accountant or a CPA.
Jeff: This is worth unpacking, because I think there's real confusion about what an HR company actually is. If I'm an employer and something comes up, technically I'm supposed to call an employment attorney, but most people don't actually have one, they have an attorney, just not one who specializes in employment law. Does an HR company typically have attorneys on staff?
Ashley: Usually, and that's worth confirming when you sign up with one. But their real purpose is compliance.
Jeff: So they help build your employee manuals, make sure you know things like required break intervals, or that you have to pay someone for travel time to a training course?
Ashley: Exactly, and this is precisely the problem, all of that varies state by state, so you need someone who genuinely knows the rules in your specific state. They typically help with minor firings, hiring and onboarding processes you might not realize you're required to have, rules around what you're legally allowed to ask a candidate in an interview, and when you're allowed to run a background check.
Jeff: Background checks specifically seem important. Have we had clients dealing with embezzlement where it turned out the person had done it before somewhere else?
Ashley: Yes, and they only found out afterward, because no background check had ever been run. But you have to know the actual rules around this too. In California, for example, you can't run a background check until after you've made a conditional job offer, again, not legal advice here, so I'd have to say, I'm offering you the position pending a clean background check. If it comes back clean, they're hired. If it doesn't, say it turns out they'd stolen from a previous employer, you're able to withdraw the offer.
Jeff: Got it.
Ashley: So having an HR company means you actually have access to the tools you need to hire and run your practice properly, which, again, has become just as standard now as having an accountant. Because you have to be more judicious about who you hire in general, when someone's asking for $22 an hour for a role you would have filled at $15 a few years ago, you need to spend those dollars intelligently, the same way you'd shop carefully for a lab or a supplier. Part of that is knowing what you're legally allowed to ask and do during hiring, and then, once someone's hired, how to actually train them properly, for instance, you can't send someone home to complete training on their own time without paying them for it, that's a real compliance issue.
Jeff: Definitely worth checking with your own attorney or HR company on specifics there. Two quick questions on this. First, do you have a specific company you'd recommend?
Ashley: A lot of our clients use CEDR.
Jeff: I'll put a link to them on the episode webpage, to be clear, we're not affiliated with CEDR, but we've had a lot of clients use them and been satisfied. ADP also has a full HR division.
Ashley: Right, that's actually who we use ourselves, through our payroll service, alongside our own employment attorney. Both CEDR and ADP are nationwide options, though plenty of our clients also use smaller, local HR firms.
Jeff: Second question, and you may not know this off the top of your head, but roughly what does something like this cost?
Ashley: It varies by package, number of employees, and what services you want, but I'd estimate mid hundreds to low thousands of dollars a month.
Jeff: Significantly less than the cost of actually getting sued.
Ashley: Exactly. I've seen clients face real lawsuits, usually newer clients we hadn't yet had the chance to properly advise, tens of thousands of dollars over things like break rule violations they simply didn't know about. And what's interesting right now is you're seeing what look like attorneys actively trolling for exactly this kind of case on social media, did you get your legally required breaks, did you receive your sick pay. In a reasonable world, if someone felt shortchanged on a break, they'd just mention it to their employer directly. Instead, it's becoming something people sit on quietly until they've built up enough of a case to file a formal complaint.
Jeff: That's a rough position to be caught in.
Ashley: It really is. So the solution is getting an HR company in place and asking directly, what are the major compliance points that actually carry the biggest liability for me right now. We obviously all know the big ones already, harassment, discrimination, unfair labor practices, nobody's debating those. It's the smaller, more technical compliance issues that catch people off guard. And it's worth noting, a genuine harassment or discrimination complaint rarely starts with someone saying I was discriminated against directly, it usually starts as something vaguer, so-and-so made me uncomfortable, and as the employer you're actually responsible for recognizing that and following up appropriately. Your managers need real training on how to recognize these situations, not because you expect them to happen, but so they're prepared if they do.
Jeff: Our own employment attorney mentioned using actual clips from The Office as training examples, this is exactly how not to handle personnel issues.
Ashley: Genuinely true, that's actually used in some real training courses.
Jeff: So, pay and compliance are the two biggest pressures. What specific changes have you made, or had clients make, in response to all this?
Ashley: On the payroll side, we personally move a lot faster in our own hiring now. We don't carry as many redundant staff just in case we lose someone, we used to keep extra administrative assistants around specifically so we could slot someone into an open role quickly. Now we just hire faster instead, we have a strong hiring specialist, and if we lose someone, we know we might go a week or two short-staffed while we backfill, and we manage through that instead.
Jeff: Walk me through how the actual hiring process has changed. We used to bring someone in, and if we were seriously interested, we'd schedule a second interview before extending an offer.
Ashley: Now it's almost entirely same day. Someone comes in, and if they make it through, we're extending an offer that same day.
Jeff: One other thing worth asking, did we see a lot of candidates ghosting interviews a few years back, especially post-COVID?
Ashley: We did see some of that, clients experienced it more than we did directly. During those first couple years post-COVID, a lot of people were collecting unemployment and had to show they were actively interviewing to keep receiving it, which produced a wave of interviews nobody ever intended to follow through on.
Jeff: Is that still happening now?
Ashley: I think we're mostly back to how things were pre-COVID on that front. But we've kept the faster hiring process regardless, we tell clients this constantly now, you have to move quickly. When our hiring specialist likes a candidate, we run placement testing, one of our executives meets them the same day, we run the background and reference checks immediately, and ideally an offer goes out that same day. That process used to take two or three days.
Jeff: Good candidates get snapped up fast.
Ashley: Exactly, if they're genuinely good, you want to move on them immediately.
Jeff: Any other significant changes?
Ashley: We had to adjust our own pay rates too, starting pay has gone up across the board, and that's on top of minimum wage itself climbing significantly nationwide.
Jeff: It's not always official minimum wage either, Chipotle's starting pay a few years back was $15, and I believe California has a $20 minimum specifically for fast food workers now.
Ashley: Right, so if someone can get hired at a fast food counter for $20 an hour without much real effort, they're simply not going to take a more demanding role for less than that. So you end up needing to offer $22 or $23 just to stay competitive against that baseline.
Jeff: So we adjusted pay, but we've also gotten more efficient and faster at training people to make that investment pay off.
Ashley: Exactly, onboarding used to run about a day, now it can run up to three. We spend a lot more of that time making sure someone genuinely understands the organization as a whole, how the different areas actually work together, not just their own specific task list, since that foundational understanding is what actually lets them succeed quickly once they're on the job.
Jeff: Has that same urgency shown up on the other end too, letting go of people who aren't working out?
Ashley: Absolutely. Not that we're trying to fire people, but we give far fewer chances than we used to. If someone comes in asking for $20 an hour with no real experience, or two years in an administrative role, I understand we have to pay that rate now, but in exchange, I need to see genuine initiative, real effort to succeed. We'll pay you fairly for that effort, but if I don't see that drive, I'll find someone else who'll do a better job for the same money.
Jeff: And to be clear for anyone thinking hiring is genuinely impossible right now.
Ashley: It's not that people aren't looking for work, they are. What I typically find is clients simply aren't running enough ads, aren't interviewing quickly enough, or they post a job and don't even review resumes for three days. People looking for work don't wait around that long.
Jeff: We also adjusted our own pricing to reflect this new reality, since we've had roughly 26 percent cumulative inflation, officially, from March 2020 through August of this year, and it's likely higher in reality, especially in categories like gas and food. So costs have genuinely gone up, and this connects directly to something that used to be a nice-to-have piece of advice, getting out of insurance plans, and has become something closer to a necessity. If you can't control your own prices because 80-plus percent of your practice is locked into insurance networks, you're in real trouble, because none of your other costs are discounting themselves to match, not your employees, not your marketing company, not your landlord.
Ashley: Right, nobody's saying, sure, I'll take 60 percent of my normal rate because you're stuck on a PPO. And here's something interesting I've noticed, a lot of it comes down to being a product of your own conditioning, being a millionaire meant something very different in 1985 than it does today, you'd basically need to be a multi-millionaire now for that same relative significance. The same thing applies to wages, it's not just that pay has adjusted for inflation, in a lot of cases we're paying meaningfully more than inflation alone would explain, since candidates today expect more than the strict cost-of-living increase would justify.
Jeff: That connects to something I've noticed too, if I hire someone at the very top of a given pay range, say the role pays $50,000 to $75,000 and they ask for $85,000, and they check every other box, I might still bring them on. But the internal pressure on that person is considerably higher, since every week that goes by without them clearly outproducing someone I could have hired at the lower end of that range starts to feel like it isn't working.
Ashley: Which is exactly why real training matters so much right now, on both sides. As an employee, you genuinely have to get yourself trained and learn how to actually function within an organization. And on our end, we're training considerably more client staff than we used to. We run a program covering an entire team, front desk, assistants, everyone, called our All-Inclusive Program, and enrollment in it grew substantially this past year.
Jeff: Just to clarify for anyone confused, our main program, the Power Program, trains the doctor and office manager directly. Once a client is doing well and wants to build multiple locations, or grow a single office to $600,000, $800,000, even a million a month, they need considerably more trained staff supporting that. That's what our three-year All-Inclusive Program is for, training an unlimited number of staff as genuine executives, which ends up far more cost-effective long term than paying for ten separate individual office manager programs. We sold more of those last year than in any prior year.
Ashley: Right, and people are signing up sooner too, not just our established Power clients. We're seeing doctors join our main program and enroll in All-Inclusive within a month or two afterward, because they recognize immediately, as they start their own training, that they need their team trained right alongside them. We're also seeing considerably more engagement on our online training platform, DDS Success.
Jeff: I'll put links to the Power Program and DDS Success on the episode webpage, I don't believe we have a direct link for the All-Inclusive Program specifically, since that's generally something you qualify for once you're already on the Power Program, but feel free to call us directly if you're curious about it.
Jeff: So circling back to something you said, the employee has a bit of pressure on them in this scenario, but so does the employer.
Ashley: Exactly, there's real pressure on you as the employer now to make your team genuinely efficient. If you think you can simply hire someone perfect who arrives fully formed, the odds of that are genuinely slim, because if someone's already excellent, wherever they're currently working has likely already invested in training them and will work to keep them, paying them a bit more to retain that investment rather than starting over. So you have to be willing to start essentially from zero with a new hire and build them quickly. What used to take two years to build a fully capable office manager now needs to happen in three to six months, sometimes starting from someone with genuinely no prior experience at all.
Jeff: Beyond what we've already covered, are there other common staffing problems you're seeing specifically with newer clients?
Ashley: Understaffing is the biggest one. They genuinely need five people and have two or three, and instead of addressing that directly, they look for ways to cope with being understaffed instead, outsourcing their front desk entirely, doing their own hygiene, performing procedures without an assistant. They think the adjustment they need to make is having fewer staff, when the real adjustment is the opposite, generating more revenue by seeing and helping more patients, and getting out of insurance plans that are suppressing that revenue in the first place.
Jeff: What would you say is the biggest overall mistake you see newer clients making with personnel specifically?
Ashley: Coping with the wrong employees instead of actually replacing them. They'll hire someone below the going market rate, feel lucky about the savings, but there's usually a real reason that person came in under market, and it isn't the right fit. Rather than addressing it, they cope, shrinking that person's actual responsibilities and quietly absorbing the difference themselves, an office manager working 60 or 70 hours a week to cover for an employee only working 40 for less output. Or they cope by simply not hiring at all, running understaffed rather than confronting either problem directly.
Jeff: If someone listening could only take one thing away from this conversation, what would it be?
Ashley: That personnel is no longer a line item you can just get by on and hope it works out. I've told you to get an HR company, I've told you you'll likely need to pay more, and at this point some of you are probably thinking, I don't want to do any of that. But it's genuinely not something you can keep ignoring. Whether that's the risk of a lawsuit from ignoring shifting compliance laws, or running such a bare-bones staff that your practice simply can't grow, which means your own team can't grow financially either, no real bonuses, no real advancement, and eventually your profit declines and you're looking at selling or closing entirely.
Jeff: That's a genuinely sobering way to put it. One clarifying point, on the pay side specifically, say I've lost a front desk employee and need to hire, and candidates are asking for considerably more than I was previously paying. How do I actually know whether that's reasonable or excessive?
Ashley: I like using salary.com as a starting point, but I'd also do a broader search, checking Indeed and Glassdoor too, since those show you what other practices in your specific area are actually advertising and offering right now, which sometimes runs ahead of what a site like salary.com reflects.
Jeff: So if salary.com says $20 an hour but everyone in my actual area is advertising $23, I need to be paying closer to $23 to stay competitive.
Ashley: Exactly. And this is actually a great place to use AI productively, ask ChatGPT to run a sweeping search for you, here's my area, here's the role, tell me what people are currently paying, giving it clear, specific direction. It saves you from manually digging through every site yourself.
Jeff: That's a great point, and I think it's worth saying plainly, don't just take my word or Ashley's word for it that you need to pay more, actually go look for yourself and confirm it for your specific market. You have to spend real time on this now, in a way you probably didn't have to in the past.
Ashley: Right, and an HR company can often help with exactly that too, giving you a real sense of what's genuinely competitive in your specific area.
Jeff: I think the real lesson here, if I were listening to this, is that personnel used to be just one more thing you handled in running a dental practice, the people helping you deliver care to patients, without needing to think much about the more complex layers underneath it. Now you genuinely have to actively manage this area.
Ashley: Right, you don't need to become an HR expert yourself, but you do need a genuinely good HR company backing you, along with solid, basic hiring policies actually in place, so you're covered and staying on top of it.
Jeff: It's really no different than marketing in that sense, you either understand it or you don't, but now personnel needs that same level of genuine attention.
Ashley: Exactly right.
Jeff: Ashley, thank you so much for being here today.
Ashley: Thanks for having me, this was great.
Jeff: Folks, I've got links to the Power Program, DDS Success, and CEDR on the episode webpage. If you'd like to learn more about MGE, you can find us online at mgeonline.com, or call us at (800) 640-1140. Have a great week, and we'll see you at the next episode.