The instinct in a tighter economy might be to protect your practice by discounting treatments or requiring more cash upfront to guard against risk. OrthoFi’s data over the past 8 years shows that either of those choices would be a mistake.
We’ve consistently found that when you optimize for case acceptance, rather than trying to maximize cash flow or minimize risk, a healthy, balanced portfolio follows.
Patient affordability isn’t just a patient experience issue. For Orthodontic Service Organizations and Dental Service Organizations, it’s a growth and profitability issue.
In this blog, we’ll cover the data-backed strategies you can use to optimize your organization for conversion and grow net production, all while maintaining treatment fee integrity.
For a deeper dive into this topic, watch our free webinar, Ortho at Scale: Patient Affordability
The Macro Situation: A Competing-Priorities Problem
“The consumer is under stress in 2026. We’re moving from a period of time where the question that patients were thinking was, ‘Can I afford treatment?’ And the new question that they’re really focused on is, ‘Can I afford the monthly payment?’”
— Dave Ternan, Co-Founder & CEO, OrthoFi
The temporary cushion many households built up during the pandemic has disappeared. Household debt is up sharply since 2019, while the personal savings rate has fallen just as dramatically.
That erosion of savings shows up clearly in a simple stress test: could a US adult cover an unexpected $400 expense with cash? That figure peaked at 68% during pandemic-era relief programs and has since settled back to 63%, in line with 2019 levels. More than a third of adults can’t say yes to that question today.
Delinquency is rising too, across credit cards, auto loans, student loans, and mortgages, a sign that financial stress is broad-based rather than isolated to one type of borrower.
What does that mean for OSOs and DSOs? You’re not just competing with other practices for a patient’s dollars. You’re competing with every other line item their household wants or needs to cover.
If you’re still requiring a $400 down payment, you could be driving away a third of patients who couldn’t find that cash, including some who might otherwise be ready to accept treatment.
This requires a total rethink of the old way of patient billing. It’s not just about the total cost of treatment. It’s about whether patients have the cash for the down payment and whether the monthly payment fits within an already crowded budget.
The Same Story Shows Up in Orthodontic Practice Data
The macro trends we’re seeing on the national level are showing up directly across the OrthoFi fleet.
Average down payment per start peaked in 2021 and has declined about 9% since then, from $741 to $673, even as treatment fees have continued to rise. Same-day cash and pay-in-full percentages have followed the same downward path from their 2021 highs.
Despite these trends, our practices continue to see growing net production per start when they give patients the flexibility to find a payment structure that works for them.
When given the choice, patients are reducing their down payments and absorbing costs primarily through modestly longer terms and higher monthly payments.
These results make a compelling case that maximizing down payments to protect cash flow is not the right strategy for 2026. Instead, practices should be designing their payment plans to provide affordability, not asking patients to shoulder more risk upfront.
Three Levers to Optimize Conversion
Every practice is managing three competing forces: conversion, cash flow, and risk. When you pull one lever, the others move.
Maximize cash and minimize risk by requiring high down payments and tight terms, and conversion suffers. You’re asking financially stressed patients to put more down and pay more per month than they can manage.
Maximize conversion alone, with zero down and rock-bottom monthly payments across the board, and cash flow and risk exposure both suffer.
So what should you be focused on?
We believe that the right move is to lean into conversion. It’s not about maximizing. It’s about optimizing.
Our data shows that when you reduce barriers to affordability, balancing cash flow and risk, you start more smiles. The higher conversion rate you see more than makes up for the added risk exposure.
Let’s look at the strategies you can use to optimize for conversion.
Strategy 1: Open Choice Payment Plans
Down payments are down across the industry, but practices still need to cover lab bills and day-to-day expenses. The strategy we’ve found most effective at driving starts while preserving cash is open choice.
With open choice, you give every patient the flexibility to find a treatment plan they can afford. OrthoFi practices use a payment slider to let patients choose their own down payment and monthly payment within a set range, rather than being handed a single, rigid plan.
The fear is that when you give patients flexibility, everyone will choose the lowest possible payments.
Across nearly 2 million starts, our fleet data shows that patient choices are far more varied than most practices assume. In fact, many of the plans real patients select seem to defy conventional logic.
The crucial finding is that at the portfolio level, higher-commitment patients help offset patients with lower down payments and longer terms.
Across the OrthoFi fleet, we see a healthy pay-in-full rate of 22% and a same-day cash average of $1,354 per case. That’s enough to cover the lab bills for lower-cash patients, including those who might not start treatment at all under a single, rigid plan.
Quick Tips to Balance Risk and Cash Flow
- Keep target down payments well below $500. Monthly payments in the $180 to $210 range are the sweet spot to aim for.
- Offer patients the opportunity to sign at home. Patients who choose their plan at home tend to select higher down payments, more same-day cash, and more pay-in-full options than patients who choose in the office with a treatment coordinator present.
- Provide incentives. Encourage those who can afford a stronger down payment or shorter payment terms to commit more upfront, without making it a requirement.
Strategy 2: Credit-Tiered Guardrails
Open Choice doesn’t have to mean payment terms should be completely “open” across the board. You can and should still add guardrails to reduce risk.
OrthoFi uses a risk profile including a soft credit check to sort patients into six risk tiers, then applies guardrails based on each tier’s profile.
We recommend that practices set minimum down payments, maximum terms, and financing guardrails by risk tier, rather than applying a single, one-size-fits-all policy across the whole patient base.
This way, you can create more paths to treatment while protecting your practice’s cash flow and portfolio quality.
Regardless of credit score, we find that patients are looking for the same thing: monthly affordability.
Remember, strong creditworthiness reflects bill-paying discipline, not necessarily more disposable cash. In our fleet data, monthly payment preference is relatively flat across all tiers, with average monthly payments ranging from $192 to $209 in 2026.
To achieve monthly affordability with larger treatment fees, it can be helpful to extend the payment term length beyond the treatment length, at least in the case of lower-risk patients. Despite the common fear that patients will stop paying after their treatment is complete, our data shows that with guardrails in place, this is not the case.
Quick Tips for Applying Smart Guardrails
- Good credit does not always mean more disposable income. Across credit tiers, give patients the flexibility to optimize around monthly affordability.
- Provide lower down-payment options to reduce upfront friction across tiers. Offer incentives to pay more up front to protect cash flow and cover lab fees for lower-cash patients.
- Extended terms are an effective strategy to bring monthly payments down around the $200 threshold, with relatively low delinquency and write-off risk.
Strategy 3: Operational Discipline
Payment flexibility only works when it is supported by a consistent and disciplined collections process.
The key is to set your structured terms, and don’t override them.
Not surprisingly, across OrthoFi-powered practices, locations with stronger credit profiles generally do have lower write-offs. But that’s not the whole story. Regardless of credit profile, practices can outperform expected write-offs by following operational best practices. 
We’ve found that four operational best practices are most strongly associated with lower write-offs, independent of credit score:
- An optimized, structured plan configuration
- Not overriding the guardrails (overrides accounting for 5% or less of cases)
- A valid cell phone on file (for at least 99.3% of patients)
- Active auto-pay enrollment (for at least 83% of patients)
OrthoFi’s fleet-wide average write-off rate sits at 2.75%. Locations that follow the four recommendations bring that down to just 1.61%, an improvement of more than 30%.
Collections discipline matters just as much once a payment is missed. For our fleet, this means early, consistent, multi-channel outreach starting on day zero, escalation around day 45, and disciplined write-off timing.
Timely write-offs aren’t a failure. They’re a financial discipline.
Once an account is more than 60 days past due, the odds of collecting the full balance drop sharply. As balances continue to age without write-off, they’re not just sitting on the balance sheet. They’re consuming operational resources that should be focused on recoverable accounts.
A disciplined protocol allows practices to offer greater affordability upfront while maintaining confidence that delinquency and write-off risk will be managed.
The final key to operational discipline is to measure your location-level data on an ongoing basis. Pay close attention to KPIs including conversion rate, same-day cash, average payment plan length and monthly payment, delinquency, and write-offs, and be ready to course-correct over time.
Affordability is a Growth Strategy, Not a Concession
Affordability pressure is real, but it doesn’t have to come at the expense of growth or profitability.
When you optimize for conversion, the goal isn’t to drive starts at any cost. It’s to build payment structures that support patient access and business performance at the same time.
The organizations that perform best in this environment will be the ones that adapt, not by discounting treatment, but by focusing on monthly affordability, patient choice, and production quality.
Want the full data and strategy breakdown? Watch the full Ortho at Scale: Patient Affordability webinar.
