Dear friends, partners, and colleagues,
These are unprecedented and uncertain times. Most of you have decreased or stopped treating non-emergency patients in accordance with the CDA guidelines.
No one knows exactly what the future will bring. We certainly don’t. But we wanted to write to everyone to help us navigate the challenges ahead.
Some of these challenges are obvious. We’re being asked (and, in some counties, ordered) to stay in our homes and avoid contact with others. The markets are falling dramatically. Small businesses, including your dental practice, are struggling across America.
But America was built on struggle.
Morgan Housel recently remarked on how times of pain and need make innovation necessary. “The Great Depression brought unimaginable financial pain. It also brought us supermarkets, microwaves, sunscreen, jets, rockets, electron microscopes, magnetic recording, nylon, photocopying, teflon, helicopters, color TV, plexiglass, commercial aviation, most forms of plastic, synthetic rubber, laundromats, and countless other discoveries.
Same for World War II, which is responsible for both the most risk and the most rapid invention of any six-year period in history. The war began with troops on horseback. It ended by splitting an atom in half.”
And to put the market decline into some context – as of this writing at 9:45am on March 18th the S&P 500 index currently sits at April 24, 2017 levels, when people were shocked at how high the market had risen.
So what are we supposed to do today?
It’s ok to step back for a minute. The constant news updates about the coronavirus (a crazy 15% of all daily web traffic) can overwhelm the mind. Ironically, our desire to gain control through a steady diet of information can actually result in a kind of mental paralysis and our losing the ability to act. It’s a vicious cycle: we worry, we try to use information to control our environment, we worry more. This constant anxiety paralyzes the mind.
One simple way to regain agency – our ability to act – in challenging times (and this is for me as much as anyone) is to intentionally limit our media exposure. Take a deep breath.
If you’re able to spend more time with your loved ones, be grateful for that. If you have kids, play games (just not the one where you use toilet paper to turn yourself into a mummy). And if your loved ones get to be a bit much, go for a walk or lock yourself in the bathroom (there’s another toilet paper joke here, but I can’t find it).
Look ahead, plan, and execute.
This is the time when leaders will get out in front. I know several doctors who are using this time to train staff or go chartless. Almost every crisis is an opportunity. You’re taking a break from seeing patients – use this time to work on your business instead of in your business.
That’s what I’m planning to do. At Integrity Practice Sales, we have a mission. Here it is:
“Selling a business is hard, and most dentists don’t have the tools they need to get the best price and terms in today’s dynamic market.
Our mission is to deliver the expertise, support, and network required for a truly successful practice sale, so that dentists can financially support their loved ones, protect their reputation, and leave their practice in good hands.”
I’ll be recalling that mission today especially and using this strange week to recommit myself and our team to that important work. (By the way, if you want to discuss the future of dental practice sales and transitions, feel free to email me directly. I’d love to hear from you at firstname.lastname@example.org.)
Am I worried about what things will look like on the other side of this pandemic? Of course. But I have a high degree of confidence that:
- People will continue to require dentistry (including the backlog of people missing treatment because of the temporary shutdown).
- Dentists will help those people.
- We will work to help those dentists.
Is it future proof? Not exactly, but I’m moving forward. And we’re not going to stop preparing practices to go on the market, showing practices, speaking with potential buyers, and working to put solid deals together.
You can use this time to work on your business, too. You probably also have a mission, whether it’s promoting healthy smiles or providing excellent care to all of your patients.
There are ways for you to enact your mission today, even when your practice is closed. Reach out and reassure patients. Everyone is looking for a word of encouragement or comfort right now – offer one! Post content on social media. Dentists have been infection control experts for decades. Use that knowledge to inform and reassure the public.
And you can absolutely make the most of this downtime by working to build your team, your marketing, and your systems.
Dr. Bill Kimball at Kimball Consulting, Inc. is utilizing ZOOM conferencing to continue team training during the downtime. You can try this as well. Since employees CAN utilize unemployment insurance for reduced hours (and without the one week waiting period), it’s fine to ask the team to join you in person at the office (with proper distancing), on the phone, or with video conferencing.
1 – You now have time to address those systems that have fallen by the wayside, such as:
- New Patient Protocols
- Case Presentation
- Financial Arrangements
- Insurance or Membership Plan Discussions
- Delta Premier Updates
2 – Get organized for reactivating charts. Knowing that your practice will be very busy once you and your team are safely back to work, you can call patients now to schedule in a few months. Dr. Bill Kimball suggests you take the next week to get organized and perhaps start calling patients as early as next week.
3 – Update your HR manual. The CDA has a free version online for members. It takes a little time and it’s cumbersome (even boring), but you really need an up-to-date copy and now might be the time to complete it.
4 – OSHA or HIPAA, CPR, or medical emergency training (all done virtually of course)
Here are a few more highlights to navigate some of the unique challenges that this unprecedented historical moment presents.
The IRS extends us some good news: “Individuals and businesses will have an extra 90 days to pay the IRS if they owe additional income tax for 2019, Treasury Secretary Steven Mnuchin said Tuesday.” Federal Tax Extension (CNN link)
So does California: “This relief includes moving the various tax filing and payment deadlines that occur on March 15, 2020, through June 15, 2020, to June 15, 2020. This includes:
- Partnerships and LLCs who are taxed as partnerships whose tax returns are due on March 15 now have a 90-day extension to file and pay by June 15.
- Individual filers whose tax returns are due on April 15 now have a 60-day extension to file and pay by June 15.
- Quarterly estimated tax payments due on April 15 now have a 60-day extension to pay by June 15.” CA Tax Extension for Affected Taxpayers (That’s all of us, right?)
Your team CAN file for unemployment benefits: “If your employer has reduced your hours or shut down operations due to COVID-19, you can file an Unemployment Insurance (UI) claim. UI provides partial wage replacement benefit payments to workers who lose their job or have their hours reduced, through no fault of their own. Workers who are temporarily unemployed due to COVID-19 and expected to return to work with their employer within a few weeks are not required to actively seek work each week.” EDD COVID-19 Resources Page
We will get through this. It’s going to be a challenge, but it’s a challenge to which we can all rise together. These moments of great necessity become moments of great innovation.
All the very best to you and your families,
The Team at Integrity Practice Sales.Read More
What smart dentists understand about potential recessions, election-year jitters, and the practice sales market in 2020.
There seems to be a pervasive feeling that the economic outlook is too uncertain to make the jump into dental practice ownership. I have spoken to more than a few dentists recently who are concerned about the future and who suspect that it would be better to wait before they start reaping the rewards of practice ownership.
It can be difficult to feel positive about the future. Our fast-paced, 24-hour news cycle consistently confronts us with reasons to worry. The pundit class seemed all but convinced over the summer of 2019 that the economy was due for a recession (far fewer of them are talking about it now). The current impeachment drama and the impending presidential election have dominated the news for months. Escalating conflicts around the world give us new reasons to worry.
I don’t want to downplay the importance of being informed about the world around us. But pending catastrophes get clicks, and clicks generate income. Most of the news media is incentivized to keep us on the edge of our seats, anxiously refreshing our browsers to consume the latest headlines (and see their ads).
Unfortunately, all this can contribute to the feeling shared by some dentists that the economy is shaky and 2020 is not a good time to act. On the contrary, I believe that the smart move is to invest now and move your career forward.
My argument is simple and can be broken into two parts.
- The economic outlook for practice ownership is good.
- Practice ownership remains the best option for most dentists from both a financial and quality of life perspective.
Now, I know I run a dental brokerage and it’s in my best interest to say this. But hear me out. There are many good reasons to be positive about the business of dentistry and the many opportunities for both first-time buyers and seasoned multi-practice owners. In this article, I’d like to share a number of reasons to feel optimistic about these opportunities, especially as we head into 2020.
US News and World Report just released its lineup of the Best Jobs of 2020. In 2nd place, coming in after software engineer (but with almost 50K more per year in median salary) is General Dentist. Orthodontist ranks #4 and Oral Surgeon comes in at #9.
Does it surprise you that 3 of the top 10 jobs in the US this year are dental related?
It shouldn’t. The population is growing and the demand for dentistry remains consistent. Dentistry is a great profession.
The Economic Outlook for Practice Ownership is Good
Markets expand and contract and business cycles will continue to roll. While the panic that a recession was imminent has died down, we know that the future holds both good times and bad. In spite of this, I think dentists should feel confident about the future. Here are three reasons why.
Reason #1: Dentistry is recession resistant.
Will bad times crush your practice?
The Great Recession (officially December 2007 to June 2009) is considered the most significant economic downturn since the Great Depression. It caused personal and financial strain for a great number of people, including some dentists.
In their April 2019 JADA article titled, The effect of the Great Recession on the demand for general oral health care and orthodontic care, authors Albert Guay, DMD and Andrew Blatz, MS conclude the following: “The downturn in the status of the general economy during the period of the Great Recession resulted in a decrease in the demand for general oral health care and orthodontic care in the United States.”
This sounds bad, but it misses an important caveat. Compared to the rest of the economy, dentistry fared remarkably well. And the ‘downturn’ they speak of was not very pronounced at all. Here’s a chart from that same article:
The top line tracks the percentage of the total US population with GP Dentist visits. In 2003, the figure was 41.2% (representing 119,616,627 visits), while in 2015 the figure was 39.2% (representing 125,959,071 visits). In those same years, average annual per patient spend (for GPs) increased only slightly, from $589 in 2003 to $601 in 2015.
But because the population grew, the actual number of visits grew by almost 6.5 million. And total dental expenditures increased by just under 4 billion dollars.
There are many factors at play here, but the primary takeaway is that – even as demand for dentistry may have decreased somewhat during the recession – the clinical need for dentistry did not go away. This constant need for dentistry is one of the reasons that the profession featured so highly in the US News jobs ranking.
This need persists through good times and bad, which is what prompted Gordon J. Christensen, DDS, MSD, PhD in his article titled Positive changes in dentistry related to the “Great Recession” to remark:
However, as the economy recovers and patients have more income, they must return to their dentists after prolonged periods without routine oral care because of potentially extensive oral therapy needs. As they do so, many will find that postponing their oral care has caused significant and extensive need for treatment of various oral problems.
I have seen hundreds of dentists in private practice succeed through economic upturns and downturns. Buying a dental practice is an investment, and there are many ways to maximize that investment. Hiring a quality dental management consultant can make a real difference by providing good advice, training for your team, and (most importantly) helping you grow into a better leader and savvier businessperson. I’ve seen doctors whose practices grew like crazy over the recession by sticking to fundamentals.
Reason #2: Consumer confidence isn’t as bad as you might think.
Despite strong job numbers, record highs in the stock market, and historically low interest rates, confidence in the future of the economy seems to have been down in the minds of some. However, most consumers are confident. A recent CNN poll found the following:
Looking ahead, nearly 7 in 10 expect the economy to be in good shape a year from now (68%), the best outlook in CNN polling since December 2003. The new finding includes 63% who say things are good now and will continue to be good next year, while just 9% say the economy is currently good but will turn south in 2020.
Consumer opinion fuels economic growth, and confident consumers are a good sign.
Reason #3: Lenders remain confident.
The best part of all this – you don’t have to take my word for it! The banks and their teams of economic prognosticators have not put the brakes on lending to dentists. To the contrary, they are lending more than ever before.
According to Burnett Facer, VP at Zions Bank,
Applications are up and loan volume for 2019 was up 60% over the previous year. Rates are at historic lows and well qualified borrowers have multiple offers to choose from. We are seeing well run practices continue to thrive and expand both internally and externally.
The reason why is simple: the percentage of dentists who default is lower than other small business owners. Buying and operating a dental practice is a solid and generally very safe investment.
Matthew Christie, Regional Director at Lendeavor and Jason Schneller, Director of Business Development at Lendeavor highlight why dentists stand out:
From a lender’s perspective, dentists are highly educated borrowers and amongst our economy’s hardest working entrepreneurs. They understand the implications of maintaining good credit and preparing themselves for practice ownership. While nothing in life is guaranteed, if you’re a dentist with around a year of experience, a good credit score, and a demonstrated ability to produce dentistry, the chances of you getting a loan are very good, even if you have a good amount of student debt. Investing in private dental practices has remained relatively low risk over many years.
Lenders (and their risk-averse underwriters) are continuing to lend 100% of the purchase price (often with working capital), and they’re offering historically low interest rates. These terms would be unthinkable for other business owners, especially if they had the type of debt carried by many young dentists. But the facts speak for themselves: the lenders are confident in you and your profession.
Why does practice ownership remain the best option for dentists?
The economy will have its ups and downs and consumer confidence will wax and wane. When looking at the financial benefits of practice ownership, a piece of classic investing advice is in order: time in the market beats timing the market.
In other words, as long as you’re planning to be in private practice for over 5 years, the time to start reaping the rewards is now. While the parallels aren’t perfect, consider Bob, the world’s worst market timer. Bob only purchased stock at the worst moments in the last 30 years – just before every downturn, yet – through time in the market – he still came out very much on top. (The whole detailed story is fun and worth reading.)
Buying a dental practice is an investment, and it pays off MASSIVELY over time.
Here’s a little rundown on the 7-million-dollar difference between being an associate for 30 years and being an owner (producing the same amount of dentistry) over the same period. And that’s assuming that you park that money in a savings account! Investing even 1 million dollars of that 7 million over 10 years (assuming 6% returns) would turn that initial million into almost 1.8 million.
Here’s how I came up with a 7-million-dollar difference:
Let’s say that you’re an associate producing $800,000 at 25% compensation. Your take-home income is $200,000 (not bad at all…Mom is proud and you’re beating the average associate compensation, but those years in dental school could be worth a lot more).
With more dentists entering the market, your job isn’t entirely secure, but let’s say that you keep working at the same place (a very rare feat for an associate) for 30 years.
Now, as an owner producing $800,000, your overhead is likely around 60%, meaning that your take-home income is $320,000. Let’s say that you’re still receiving 25% for the work you do, but you’re also receiving the 15% profit generated by the business. That’s a $120,000 bonus every year!
But wait…there’s more!
If a conservative 25% of the practice production comes from your hygiene department. If you continue to produce $800,000, then hygiene is producing $266,000, for a grand total of $1,066,000. Now your overhead is still 60% and you’re still producing the same amount of dentistry, but your ‘bonus’ (profit from the business) has just gone up. Your total take-home income is now $426,400.
Now let’s say you buy this practice today for $850,000 (a reasonable price for a practice doing these numbers in many California markets).
Your annual payment for the loan you take out (10 years at 5%) is $108,192.
Your take-home after debt service is $318,208.
Your tax savings on just the practice purchase over 10 years amounts to around $340,000.
Assuming you haven’t grown your new practice at all, the difference after 10 years:
Owner: 3,182,080 + $340,000. + practice equity of $850,000 = over $4,000,000
Difference after 20 years (10 years of no loan payments):
Owner: 7,446,080 + Tax Savings + Equity
Difference after 30 years:
Owner: 11,710,080 + Tax Savings + Equity
That’s 7 million dollars with no practice growth and no investing. Grow the practice by improving systems, producing more, working more days, increasing fees, or any other means, and that number goes up even further.
Buying a dental practice is an investment. It provides you with more than a job that you control; it also offers profit above and beyond your compensation for the dentistry you perform, tax-advantages, a working environment you control, and equity in an income-producing asset (your practice).
2020 is a great year to purchase a dental practice!
In some cases, doctors who sell their practices are contractually obligated to stay and work in the practice for several weeks or months after the sale to provide treatment and “introduce the patients to the new doctor”.
The benefits of such an arrangement may seem clear, even obvious. It makes sense to keep the selling doctor around for a while to talk to the patients and introduce them to the buyer, right?
In my opinion, short-term work-backs just for the sake of “introducing the new doctor” typically do more harm than good. In fact, they can be a real disaster for the buyer if the patients see Dr. Seller in the office treating some patients since they’ll wait for him or her rather than seeing Dr. Buyer.
This can complicate the transition, causing problems with team members and confusing patients. If the Seller becomes an associate and helps produce dentistry for the new doctor, then it can be an ideal situation. Here, context matters most.
Team Loyalty: It is difficult for the team to transfer their loyalty to the buying doctor when the selling doctor is still around. Even though the team knows that the practice has sold, the de facto leadership will always remain with the seller. The staff will ‘double-check’ on instructions with Dr. Seller, and it only takes a slight eye roll, or a muttered “Well that’s not what I would have done…” to lower your credibility in the eyes of your new team.
For the new doctor to assume the leadership role in the practice, it is easiest for the selling doctor to make him or herself scarce, even right after the sale. It is important for the selling doctor to be available by phone and during the non-patient time to answer questions, but if they are around the practice too often, especially when patients are there, it can cause problems.
Patient Loyalty: With patients, the selling doctor’s presence can cause even more problems. Even if the buying doctor can see a patient tomorrow, they’ll wait for months to see Dr. Seller, the one with whom they’re comfortable and often “the best dentist in the world”. Furthermore, when patients schedule an appointment to see the new doctor and, while in the office, see Dr. Seller walking down the hall, they may feel cheated. They thought Dr. Seller retired and they didn’t understand that they had an option to see her.
The outright sale is almost always the best option for a clean transition. There are a number of important strategies for transferring goodwill, like a well-crafted letter to patients and thoughtful reactivation telephone scripts, that do a much better job than a work-back arrangement.
What if the selling doctor wants to keep working? What I’m talking about here is not the same as the transition scenario where the seller stays on as an associate for several years or where the buyer and seller form a partnership (partial sale) for the foreseeable future. Such arrangements – when carefully planned out ahead of time – can be mutually beneficial.Read More
When most doctors purchase a dental practice, one of the big worries is always patient retention. Most of the value of a dental practice is in the goodwill with the existing patient base, and if those patients choose not to come back, you’re in trouble.
Fortunately, this ALMOST NEVER happens. At Integrity Practice Sales, we work hard to make sure that both buying and selling doctor work together to manage a successful transition.
Many doctors decide to write a letter explaining the transition to patients. This can be a powerful tool for controlling the narrative around the transition and can help patients feel at ease with the new doctor.[Why winning over your new staff is the key to winning over your new patients.]
As with all powerful tools, however, the transition letter can be misused and serve to confuse or worry patients. Remember that patients don’t really care who “owns” a dental practice. In fact, practice ownership rarely crosses their minds.
Instead, they want to know why their doctor is leaving (or becoming less available) and who the new doctor is. In fact, patients can be offended if they read that Dr Seller “sold” her practice to Dr. Buyer.
The transition letter should be used to thank your patients for their loyalty and friendship over the years, explain why you are transitioning (basics only), and then promote the new doctor. Preemptively thank the patients for continuing as patients at the practice and for supporting the new doctor.
Tips for a great transition letter from the seller:
- Have a professional photo taken of Dr. Seller and Dr. Buyer together to use in the letter.
- Write an introductory paragraph explaining the need for the transition and thank them for the years of commitment to the practice.
- Introduce the replacing dentist and include experience and qualifications.
- Dr Seller should become Dr Buyer’s patient and let the patients know this.
- Explain the reason you have chosen this doctor to take over your practice.
- Give a personal view of the new dentist, including hobbies and family.
- Keep this letter enthusiastic and share your optimism regarding the transition.
- Repeat your appreciation and confidence in the new doctor.
Send this letter out AFTER the close of escrow. This cannot be over emphasized. The deal isn’t done until it’s done. Once you close escrow and send out the letter, you’ll also want to call the patients that have scheduled appointments over the next few days since they will be at the office prior to receiving the letter.
A few months into the new practice, the buyer should send out a second letter.
From the new doctor (1 to 2 months after the transition):
- Greet and welcome the patient.
- Talk about your background and experience.
- Discuss common commitment and philosophies with the previous dentist and thank him or her for their support and for creating such a nice practice.
- Thank the patients for such a warm welcome and thank the team for being so supportive and encouraging.
- Encourage the patient to come by to meet you or call with any concerns.
- Express your desire to get to know the patients and promise to listen to their goals.
At Integrity Practice Sales, we provide samples and help the doctors draft ideal transition letters. But no matter who you list with or buy from, following these guidelines will help you retain the value of your new practice and build great relationships that will last for years to come!Read More
Performing due diligence on patient charts can be a big undertaking, but it should not be overlooked. By examining the charts, you can tell what type of dentistry the seller performs, how the practice cares for and follows up with patients, how patients are scheduled, and how the practice makes financial arrangements.[Check out our overview of the process of buying a dental practice.]
Chart Review: Review a few dozen of the active patient charts.
Paper Chart Count: If there are paper charts, manually count the charts and compare to the computer numbers. Be sure to only count the current charts.
Random Chart Review Notes and Log: Select a few dozen patients randomly and keep a list or log with the following information:
- Last full series of x-rays,
- last bitewing x-rays,
- last prophy,
- last perio charting,
- written treatment plan,
- written financial arrangements,
- type of dentistry (see below)
This gives you a feel for the thoroughness of the charting. Most offices have over $1,000,000 of diagnosed undone treatment. Run a report of this, but of course know that the stats just mentioned are typical and should not be cause for alarm.
Types of Dentistry: In most cases, the dentistry performed by the selling doctor should match the type of dentistry you do or intend to do. Treatment plans should appear solid and predictable, with treatment completed in a reasonable amount of time.
From my experience, getting compliant on x-rays and perio charting can be a gold mine for a new owner (or any dentist at any time). The same goes for dentists who do patchwork repairs. I would consider a “patchwork” practice that doesn’t have up to date x-rays or perio charting as a practice with tremendous opportunity for growth. Ideally, there should be plenty of dentistry left for me to do on the patients of record.
Insurance Billings Validation: Ensure that the X-rays and treatment notes seem to validate treatment billed to insurance.
Distance Patients Live from the Practice: Check the active charts as well as review a computer zip code report. Practices that have been in one location with one doctor for a long time often have many patients that have moved out of the area and still commute to the office. Be aware that some might find a new dentist closer to home rather than make the 2-hour drive (or flight) to the seller’s office.
Is your style of dentistry similar to the sellers? The selling Doctor’s treatment planning patterns should match your experience and overall dental philosophy.
Clinical questions to ask the seller:
- What is your favorite type of dentistry?
- What types of procedures do you refer out?
- What special clinical training or courses have you taken, and would you recommend I take any of these to better serve the patients?
- How often do you do periodic exams?
- How often do you take x-rays?
- How often do you perio probe and when do you refer patients to the periodontist?
- Who do you like to refer to for endo, perio, OS, Ortho, etc.?
- How are your relationships with the specialists you refer to?
- What kind of mouth splints do you use?
- What kind of whitening systems do you use?
- Do you place amalgam?
Once you have a signed Letter of Intent, it’s time to take a closer look at your potential new practice. Due diligence is one of the most important aspects of preparing for a successful dental practice acquisition.
There are several important indicators that offer insight into practice performance. In this blog post, we will look at how to assess a practice’s schedule. As part of reviewing the schedule, you should take a look at both the appointment book and the recall system.
Look at how the day is scheduled.
Picture yourself in the doctor’s shoes. Would you be comfortable doing that dentistry? If they place a crown every 15 minutes, do think you could keep up? Can you envision yourself working their schedule? While schedules are flexible, this you may want to think twice if the selling doctor is significantly more efficient than you feel comfortable with.
Reviewing the Schedule: What Many Doctor’s Miss
It might be tempting to just glance forward in the schedule and check to see that appointments are scheduled out and the days look relatively full. If you only look forward, however, you’re doing yourself a serious disservice!
If you want to find the truth, look to the past. If you only look forward, you may see an ideal schedule. It’s likely that the schedule will be full. But looking backward gives you the real picture. Does the practice have a problem with cancellation? Would you be happy performing the dentistry that the doctor actually performed, and not just the dentistry that is on the schedule going forward?
Looking at what has actually happened is as important as looking forward to ensure that appointments are being scheduled and re-care is on track.
Assessing Hygiene Appointments
There is a fairly simple formula for analyzing a hygiene schedule.
First, count how many hygiene days there were in the last 30 days. Next, count how many hygiene openings there were in that same time period. (If there are 2 days of hygiene or less per week, you may want to increase the sample size.) Then you simply divide the number of openings by the number of days.
For example, if I count back and find 40 hygiene days and, in that same time period, count 40 hygiene openings, then that practice has one opening per day. In looking at practices, I’ve found that there are usually about 0.8 hygiene openings per day (32 openings over 40 hygiene days).
If you look back and there is more than one opening per day, this indicates one of two things: either there are too many hygiene days scheduled or, more likely, the office does not keep with up with their recall system (or has a poor system to begin with). It could also mean that they don’t have a system in place to handle cancellations or they have a weak perio program.
All of these problems indicate opportunity – and having 1 opening per day is usually ok. Even the best run practices have about .5 openings per hygiene day. We’ve seen some practices with as many as 3 openings per day! Remember, if you look forward you probably won’t see any openings – so be sure to count backward.
Using these tricks can help you feel confident about your practice acquisition. If you’re considering purchasing a practice in the next 5 years, please fill out our Inside Buyer Survey and be the first to hear about new listings that meet your specific criteria.Read More
Once you have a signed Letter of Intent, it’s time to take a closer look at your potential new practice. Due diligence is one of the most important aspects of preparing for a successful dental practice acquisition.
There are several important indicators that offer insight into practice performance. In this blog post, we will look at the financial side of due diligence.
Your banker is an important member of your transition team and will help with the financial side of due diligence. Because they are looking to avoid risk, they are naturally in your corner. Your success is their primary goal – when you succeed, you make your loan payments.
The first step in evaluating a practice that you think you want to purchase is to look at the finances. You should already have determined that – based on the practice prospectus – this practice could support you and your family after you pay all of the practice expenses and the bank loan. Now it’s time to double check all the figures.
Cash Flow Sufficiency: Monthly practice cash flow must be sufficient to cover practice overhead, practice loan/lease payments, and all of your living expenses. Sometimes with a smaller practice, it is advised to keep working at an associate position until practice cash flow increases. The benefit of buying a larger practice is that it should be able to meet all of your financial obligations.
So, what is sufficient? California Dentists make $164,000 per year according to the Bureau of Labor Statistics (bls.gov). That may sound good to you, or you may be looking for significantly more. The good news with purchasing a practice is that you’ll immediately start to take home a significant income (depending, of course, on the size and profitability of the practice).
Consider asking your Dental CPA to perform a “Review of Books and Records”: While the bank does a good job reviewing the practice books and records (to protect themselves), some buyers prefer to have their own CPA review the tax records, financial statements, and bank statements.
Financial Arrangements and Accounts Receivable (A/R): Review computer or manual reports that document patient payments as well as the accounts receivable percentages. A healthy A/R might be ½ of a typical month’s collections. A high A/R (over one month’s collections) might indicate poor financial arrangements. Even if you are not purchasing the A/R, doing an A/R review gives you insights into the practice.
Purchasing Accounts Receivable: Often the A/R will be included in the sale. Typically, the price for the A/R will be calculated using one or more of several popular formulas such as;
- 100% of current A/R and 50% of everything over 30 days, or
- 90% of current A/R, 80% 31-60 days, 70% of 61-90 days, 50% of over 91 days, or
- 75% of all A/R less than 90 days
Another option is to purchase the “first $____” of the A/R. This number might be 70% of the total A/R, in other words, if the A/R total is $100,000, then the A/R would be sold at “$70,000 for the first $70,000 collected”. In this example, the last $30,000 would be collected for the seller and given to the seller, once collected, for a typical 5% fee that the buyer would charge.
Property Taxes: Review the property tax bills for tangible personal property and also real property, if applicable. Personal property is anything that can be subject to ownership except land. Real property is immovable property, such as land or anything attached to the land. Bottom line: ask your tax advisor about this.
Payment Arrangement Balances: Examine any written patient financial agreements for balances due. Office policies vary drastically in this area, from verbal “agreements” (not recommended) to solid written payment plans that include interest.
Fee Schedule Review: Review the office fee schedule and compare it to typical fees in the area. IPS can help by providing typical area fees. How often does the office increase fees, and when did the last fee increase take place?
You generally don’t want to raise fees as soon as you purchase a practice – it is much better for the seller to have raised fees in the last year. However, as with so many items, this is unique for each practice. Ask your agent and other advisors about the pros and cons of raising the fees and be sure you understand how fees affect profit. I’m not kidding. Realizing that, with a 70% overhead and increasing the fees 10%, you will increase your profit by 33% … or you will make the same if you treated 33% fewer patients. (Google the Kodak Study that was done in the 80’s for more info on this).
These are some of the most important aspects of conducting due diligence on the financial side of a dental practice. If you are currently looking for a practice to purchase, please take 5 minutes to join our Inside Buyer list and be the first to hear about upcoming practices.Read More
So you’ve just successfully closed on your new practice and you’re excited…but you’re also nervous about how the new patients will react to you. In this blog post, I’d like to share one of the most important…and most overlooked…aspects of patient retention after a sale.
Meeting the Team
Winning over your new dental team is perhaps the most important way to preserve the goodwill of your new practice and a crucial aspect to any successful transition.
The basic fact is this: most patients will be happy to work with you if the team believes in you.
Your new team will set the tone for your patients as they introduce you as a new doctor. If they express confidence and talk about how great a dentist you are, it will go a long way in building a lasting relationship with the patient. Conversely, an eye roll or critical word can damage that relationship in a way that is difficult to overcome.
For these reasons, it’s more important to win over the team than the patients. The patients almost always follow the team. I discovered this when I sold my wonderful practice and knew my wonderful patients would be weeping at my doorstep begging me to come back to the office … and they didn’t! My ego was bruised, but I saw how much the patients loved my team.
When you first meet the staff, it is crucial that you listen. Ask them what they think about the practice and how it could be improved. Ask them what they are looking for in you and how you can contribute to the continued smooth operation of the practice. Ask them about the patients. They’ve all been at this office for longer than you – don’t forget to listen!
Re-Hiring Your New Team
On the day you purchase your new practice the seller is required to terminate all of the employees so that you can hire them. This is normal and typical, but it needs to be presented to the team very carefully for obvious reasons! The team needs to be reassured that their jobs are secure (assuming this is true) and that this is a required formality. The seller must pay each employee, in their final check, for all of their unused vacation and sick days, personal time off days, bonuses, etc., according to their employment manual, as well as ensuring that any retirement plans are funded with the required amount up to the date of the sale. You will be rehiring the employees immediately after they are terminated (again, assuming this is your plan and you don’t have an employee that will be retiring, moving, or a problem employee that really shouldn’t be there).
I suggest you give your new employees the same hourly pay rate and benefits as the seller gave them, with the possible exception of retirement benefits that might be re-implemented once the practice is solidly established with the new owner. By now you should know from your due diligence what percent of collections are going towards the team, which will help determine how generous your employment offer can be, but again, it’s best to at least keep the same hourly rate.
Important Note: Some long-established practices have their employees on salary rather than hourly pay. In California, it’s very difficult to use salary pay for dental employees. Be sure to consult with an employment attorney and/or use the free resources provided to CDA members to create your Employment Manual (CDA has one that members can download) and a hiring letter that is compliant with California Law.
Winning over the team puts you on the path to a successful future with your new practice!Read More
When you’re thinking about buying a dental practice, there are two primary paths to ownership: solo practice or partnership. Will you buy 100% of the practice or less than 100%?
We are all familiar with these ownership models, especially as group practices gain popularity. 30 years ago, nearly all practices were operated by a solo dentist. Today, as practices grow, the owner dentist may decide to bring on additional dentists to continue growing the practice.
As such, you’re likely to have the opportunity to purchase part of a practice. This blog post compares the two most basic forms of dental practice ownership.
The Downsides of Associates and Associating
Associates can work well in clinics designed for associates. They can also work well in private practice if the associate never intends to buy a practice at all.
The problem comes with short term associates who say they want to buy your practice. Too often, an associate buy-in position doesn’t work out, and both doctors have to make costly changes. I believe the failure rate is close to 90%, but the ADA suggests the failure rate is *only* 70% … bad odds either way!
If you want to practice as an associate with the option to buy down the line, I highly recommend that you work out all the details prior to joining the practice as an associate. Don’t work in the practice for a few years, and only then begin to consider a purchase. If discuss the terms of a future sale up front, you’ll be much more likely to succeed.
And if you’re looking to buy into a practice, starting as an associate is probably not the best way to go. If you do want to “test drive a practice,” I suggest you have clear conversations with the seller prior to associating!
From a lot of experience, I firmly believe you do not need to practice together for a few years before buying into a practice. In fact, the longer you work together without a financial buy-in, the more likely the potential purchase will not happen.
Benefits of Solo Practice
The benefits of solo practice include more autonomy, the ability to make all the business and clinical decisions yourself, hiring and firing, marketing, scheduling, etc. Some doctors worry about vacation coverage or having someone around to discuss clinical cases with, but solo practices can work fine for vacations. I used to take 6 or 7 separate weeks off per year and very few of the patients even knew we were gone because they were not scheduled that week and we didn’t have many emergencies.
My dental friends were happy to cover any emergencies … and they were happy to discuss cases with me over lunch or at our local study clubs. I believe it’s easier to be a solo doctor (probably because that’s what I did successfully and feel comfortable with), but it’s not for everyone.
The Benefits of Partnerships
The number of group practices is increasing in California. While 61% of dental offices nationally are non-DSO (Dental Service Organization) solo practices (and about 66% in California), just about 35% of the dentists in California work in solo practice. We believe that both solo and group practices offer great ownership opportunities for dentists, as long as the group practice is formed as a well-structured partnership.
The benefits of partnerships include having someone to cover for you when you take a vacation, someone to discuss clinical cases with, and someone to share management decisions with. I’ve been in good and bad partnerships. While the good ones can be great, the bad ones can be extremely difficult. Just like getting married, when you’re joining or creating a partnership, it needs to be done cautiously, carefully, and with plenty of good advisors around you.
Either of these models can work well. It really depends on what you prefer!Read More
We all have different clinical styles and beliefs. Finding a practice that is close to your style can make the transition much smoother.
That being said, in my experience, almost any dentist can work in almost any practice … and transform almost any practice to their style over a few years.[See our guide to buying a dental practice.]
Building Clinical Confidence and Speed
Do you feel confident in your clinical ability to treat your prospective new patients? This is obviously an important factor to consider before deciding whether purchasing a specific practice is the right move for you. Especially if you go into solo practice, clinical confidence is key.
Clinical confidence comes with time, but you can always take additional training such as AGD courses, Spear Courses, residencies such as those found at Esthetic Professionals in Tarzana, or at our local dental schools. Join a study club and follow your interests. You can increase confidence in your clinical skills and speed in less time than you might think!
The number of chairs you’re used to working out of can also make a difference. Some doctors use one chair and one assistant, while other practices are designed for one doctor to work out of three chairs with three assistants at the same time. If you are experienced working with RDAEFs, this can also dramatically increase your efficiency. Typically, practice finance lenders will want to lower their risk by ensuring that you can fill the shoes of the doctor selling his or her practice. By building clinical speed and efficiency now, you’ll be better prepared to take on a bigger practice in the future.
If you have strong clinical beliefs, it can be important to decide on the non-negotiables up front.
For example, there are doctors who believe that amalgam is the best restorative material out there. Other doctors strongly disagree. One practice I work with has a sign in their bathroom above the toilet that states, “Hazmat can fine us thousands of dollars for flushing amalgam down the toilet, but we’re allowed to place them in your mouths.”
One of the benefits of being a practice owner is that you have the opportunity to can control your clinical decisions. You can always do what you believe is best for your patients.
Specialties and Special Training
Specialties or special training can also be important as you consider whether or not you want to purchase a dental practice. There are laser doctors, holistic doctors, gnathologists, cosmetic dentists who place Botox, sleep apnea experts, etc. If you have special training, it can be an ideal fit if you can find a practice with one of these specialties. On the other hand, introducing a specialty can offer a great opportunity to offer something new and grow your patient base.[Click here to join our Inside Buyers list and be the first to hear about practices that meet your unique criteria.]
General dentists might refer out all of their specialty work or keep most of it in-house. If you do have special training or want to focus on a particular style of dentistry, owning your own practice gives you the option to make this determination for yourself.
Questions to ask yourself:
- Are you confident in your clinical skills?
- What are your most important clinical beliefs?
- Do you have any special training you would like to incorporate into your clinical approach?