Episode 84 – Navigating Dental Practice Ownership

“Nowhere else except dentistry does the interview include the person asking ‘when do I take over?’”  – Chris Sands

“Hire and mentor a million-dollar associate.”

It sounds so easy. But as you probably know, it’s not.

In last week’s episode of Investment Grade Practices, we had a mind-blowing conversation about how associate relationships reduce risk in the dental practice.

As you know, part of building an Investment Grade Dental Practice is not only minimizing risk but also looking at your future and retirement goals. For many doctors, that means bringing on an associate. But not just any associate, the million-dollar associate.

In this episode of the Investment Grade Practices Podcast, we continue the conversation with  ProFi2020 Partner and Strategic Growth Financial Consultant Chris Sands; IGP Business Advisor Joanne Miles, MAADOM, RDA; and owner of Kuna Dental (Kuna, Idaho) Dr. Daniel Haws.

If you are a doctor who wants to attract a million-dollar associate, or you’re an associate wanting to join a practice that will support your dream, then pay close attention, this podcast drops pearls you won’t want to miss, including:

• Questions exceptional associates have before joining a solo doctor
• The mindsets of million-dollar associates
• How to set an associateship up for success

EPISODE TRANSCRIPT

Victoria Peterson 2:28
Welcome back to another edition of Investment Grade Practice. I’m continuing the conversation with Chris Sands, Joanne Miles, and Dr. Daniel Haws. Last episode was so intriguing and we went into after-hours just talking about it even more. So we’re going to continue the dialogue of if you are a mid-career Doctor, what it, what are some of the things you can do to maximize the value and maximize your return and we ended last time on the topic of the million dollar associate and what that does, and Chris, you pointed out a lot of great things. It sounds so easy. So we’re gonna go into the not-so-easy parts about it, but the rewards are tremendous, right? Multi doctor practices have lower risk, you don’t have one singular point of failure, if the owner and high producer go down. You also talked about if you’re the owner doctor and the top producer, that’s the worst place for you to be you should strive to mentor people to outproduce you and do that. It also having associates, that’s your debt repayment strategy. I just loved that you were saying that, like you got all those loans, let’s let’s get profitable, and have the work of the associate take care of that. So I want to pitch the question first to Dr. Haws because you’ve been an associate several times before you became an owner. What were some of the questions you had as an associate or that you hoped would have happened when you went into practice with a solo doctor?

Dr. Daniel Haws 4:10
I think some of the questions that I had were, how do I know when I’m ready to buy into practice, right? I mean, like, when am I going to be ready for this? I mean, there’s the obvious questions of like, how do I do dentistry, right and we previously talked in the previous episode there of, you know, mentorship, you being so important to an associate and feeling that they’re supported at all levels, right, but after that, it becomes like how do I know I’m ready? When am I ready? At what are their numbers that tell me that? Tell me what those numbers are? Is my skill set ready, or am I gonna fall on my face? I think those were a lot of the questions though. Do I buy the practice? Do I partner? And so and I think all associates nowadays come out with that except for they have options that I didn’t necessarily have, with as many DSOs are out out there nowadays that are hiring dentists to come work for you and saying, “Hey, we’re going to pay you this and we’re going to give you this debt repayment, we’re going to give you this health insurance,” and all that stuff that’s a little more available to these young doc’s coming out with so much debt and wasn’t really as available to someone like me coming out in the era that I did. It was, “Hey, go try and meet someone and see if they’ll let you work for him,” and you’re gonna work and make what you do right off of a commission or whatever. So I think that was, those were some of the heartaches that I had to, to deal with. So you know, what’s right, do I go with a DSO, or do I, you know, that’s something that gives me more of a step program, or do I learn with a new doc, or with a veteran doc? Do I become their associate?

Victoria Peterson 5:59
I love it. Well, once again, you’ve set us up for a great quote, a great topic and I think we’ll take both sides of the coin. So we’ll start with, you know, what are some of the things that associates should look for and expect and then we’ll we’ll flip the coin, and say, “So, owners, how do you attract and make it attractive, and when would you invite ownership into or what could contracts look like? So Chris, you just look like you’re chomping at the bit to jump in here?

Chris Sands 6:27
Well, one of the questions he also asked was, you know, that question, how do I know when I’m ready to buy in? First, first of all, I think, nowhere else but dentistry, is that that in the first interview, that question gets asked by candidates, so like, what’s the path to the partnership and we wouldn’t go, you know, working for a big company, yeah, a law firm and asked, you know, what’s that path?

Victoria Peterson 6:50
Google day one, “When do I take over?”

Chris Sands 6:52
And I think as a young doctor, it should be your goal to prove yourself, and to prove to yourself that, I’m gonna go back to the million dollars. If you can produce a million dollars for somebody else, then you know, you can carry the weight of practice ownership by yourself because once you, once you buy in, or once you buy your own practice, it’s your back against the wall, it’s you, it’s you, that’s make or break. So you have to make things happen. So now, in today’s kind of dental marketplace, I think that there is a lot less hands on clinically in dental school, they are very more restrictive, and what they’re actually getting to do. So they come out, not only slow because, you know, maybe a crown prep in dental school takes three hours, and you want to get it down to 45 minutes, but they come out just very inept to what maybe you were accustomed to in your era, coming out having done in dental school. So there’s this learning curve and if they did not do a GPR, or AEGD, I think today’s general dentist is desired by the patient, primarily the 30 to 55-year-old female, I think, desire to be the super dentist and do all things under one roof. I think implants is common nomenclature for people these days, root canals, people don’t know what an endodontist is, I think that’s a dinosaur, they expect that every dentist does root canals, come on, that’s been around for a while and pulling wisdom teeth, you know, “Hey, everybody has wisdom teeth, you’re saying you can’t pull my wisdom teeth? What’s it? What’s an oral surgeon? What’s wrong with me Doc?” Like they kept then they start to second guess like, “Are you a good enough dentist for them?” So I think it does take time for a new practicing doctor and associates to build up their their clinical skill set and then their confidence. Confidence is a big piece. I think I think confidence has gone way down just generationally. There’s a lot of self-doubt and anxiety and I think that they’ve got to come in and be super confident in you know, who they’re talking to, and how they’re diagnosing and their ability to deliver that care. I’ll pause there, I’m trying to think what the other question he asked.

Victoria Peterson 9:07
I think, I think that’s really great, though, that how do you know as an associate, when is the right time and having your own internal performance metrics? You know, I guess quite a few.

Chris Sands 9:19
I can speak financially to it. You know, if you’re going to, you’re going to finance two things. Number one, if you’re going to partially buy in, you’re going to take out a loan personally and that’s gonna be your personal after-tax loan payment. So if you buy in for half the practice, you figure out what your loan payment is going to be, will you be making more money immediately, net net? Likely not. So you got to you got to know that. Number two, liquidity-wise, banks don’t, they don’t require, they’re not going to take it from you, but they want to see that you’re a saver and for whatever reason, they’ve all told me that the magic number is whatever loan amount you’re going to ask for, they’d like to see that you have 7% of that number liquid. Okay, so if you are asking for a million dollars, I’d like to see that you have $70,000 cash and they can’t, you know, they don’t really count your retirement accounts or anything like that. So I just think that you need to know

Victoria Peterson 10:12
That’s actually not bad, that’s less than, like a home downpayment.

Chris Sands 10:16
Right, yeah, they’re not going to take it from you, they just gotta require that you have it.

Victoria Peterson 10:20
Alright, so give us the 123. Preparing. So right, there’s three ways to own a practice, you can, de novo you can scratch start, right, so you got to go and get working lines of credit and that’ll be one topic, the other is, go buy out the practice completely, or partner in at some percentage. Can you give us, because all three of those are different, right with the bank requirements?

Chris Sands 10:45
Yeah, if you do a startup, those are the highest risk, you’re gonna have, likely, you’re gonna have some sort of tenant improvement loan, because you have to install the plumbing into whatever space that you’re in, you’re going to have an equipment loan, and then you’re going to have a working capital loan or line of credit and it’s not going to be huge, in most cases, you might be if you get 100,000, working capital to get started. When it comes to buying in, or selling or buying the entire practice, the valuation and how much the banks will lend are completely dependent on the financials of the business. So they’re going to look at the last three years of revenues or collections, they’re going to look at the bottom line profit, and they’re going to take that profit, and say, “Here’s a rule of thumb, if you’re gonna take a loan, the payment is typically about $7,000 per million.” Okay, so for if you take a half million dollars might be 3500 bucks a month, take a million, its 7,000 a month, and they’re gonna see does the practice show at least that much in cash flow at the bottom line and profit. So 7000 a month is 84,000 a year, at minimum has got to have that just to cover that loan, right, but buying in is not difficult. I think the easiest is buying the practice 100%, existing practice 100%, I would say an order of difficulty, ease ease, it’s buying a practice outright, then buying into the practice is it’s easy to get accomplished in finance, I just think it’s sometimes hard for that partner to understand that they got to make that payment themselves personally just like their student loans and then the startup is just, you know, hopefully you have some cash reserves saved up, hopefully, maybe you’re moonlighting and another practice part-time to get things going, but I do see the future, in dental lending and private practice, I see the future being more heavily weighted in startups because as the consolidation happens in DSOs, by these practices, there might be less private practices to purchase. So that the true and I think that you know, the entrepreneurial dentist is becoming more and more rare out of dental school. I would I would say that most students and residents do not want to own majority do not the majority are female, majority almost don’t even want to work four days a week, they want to work three days a week, and the majority are do not want to and that’s for a multitude of reasons. I think that there’s the student loan crisis that you mentioned and they’re having heavily heavily weighted, they’re scared, they know, they’re going to cover that payment. So they’ll take the guarantee from a DSO and I think that there’s just generationally now this work-life balance, desire, where they want the life part first, you know, the, all my lifestyle and wanna be able to travel and have, you know, flexibility, more than wanting to work. So working to live not living to work.

Victoria Peterson 13:50
I love all of that and I’m going to be a proponent of please become an entrepreneur, please. Right. So the world is out there discouraging you, DSOs own the dental school. Medicaid, corporations own the dental schools, and the narrative is very, very swayed in that direction. Daniel, jump in here.

Dr. Daniel Haws 14:14
I was just gonna say, you know, I think Chris is exactly what I think you know, who’s gonna listen to this right now who’s listening to us talk and I think this is, I, there’s a few kids that I’ve met with that are coming out of dental school and I think this is a perfect little snippet podcast for them to listen to to understand. Okay, what do you at least have to know, like, what’s, what’s the most basic version of how are you going to get into this game and what kind of a game are you going to play, right? And you need to have some idea of what game is out there and what’s going to be required of you and what do you want to do, right.? And I think that Chris is exactly where I think the majority of the kids coming out of school now are more adept to fall into this DSO line, where it’s like, you know, “Hey, I just want this.” I’ve, I mean, it was a crazy thing growing up, I, no one ever really took a vacation to Hawaii. It was just the weirdest thing like, “Wow, they must be totally rich, right?” If they nowadays, I mean, kids are like, it’s just this thing, right? We just, we travel more, we love life experiences so much more. So I think that they come out and they kind of want the good right off the bat, and, and that’s great, but that’s what they value, right? So when they see the ticket from the DSO, it’s like, “Wow, I can do all of this and not have to worry about staff and not have to worry about that.” So that’s really kind of a ticket, however, the flip side of that is I have never met such entrepreneurial people in my life, as I have recently from some of these dentists coming out. They, they’re in their second of four years and they’re meeting with me, and they’re talking about opportunities, they’re talking about business. How did they know this? They didn’t even teach us that, but the information? Yeah, but that’s just it is Victoria’s out there, Investment Grade Practices out there, PDA is out there and these guys have YouTube as well and podcasts. I mean, they’re I mean, that’s how I got into this right, Productive Dentist Academy podcast, they have access to this stuff. I mean, just last workshop, Victoria, we were at the workshop, and there were dental students in the workshop and you’re like, wow, and everybody’s sitting there and we’re just applauding, like, “Congrats, guys, you figured out how to be in the game, even when you don’t know or necessarily understand.” So these kids are coming out and, and they’re ready to play even before they know how to use their hands very well, and I love that side of it and and it’s just I think for them this podcast is going to, they’re going to eat it up and say like, “Hey, what do I need? What’s this working capital? What does that really mean?” While working capital is what you’re going to need to be able to pay, you know, the marketing, pay the rent, pay all that stuff, when nobody’s coming to see you yet, because you just opened your doors and just because you open your doors and send out flyers doesn’t mean people are going to come in right away, right? No,

Victoria Peterson 17:02
I tell you, I here’s, I love your prediction, Chris, and here’s my prediction, we may have fewer as an aggregate from the class, right? So when Bruce graduated, it was just expected 95% of you are gonna go into private practice, I personally go in the military, or you know, some percentage like that, you were in the military or you private practice and you hung out a shingle. So what you did in the 70s and 80s, you hung out there and then the 80s, interest rates went really high, people went bankrupt and then the whole concept of associateship was born. You know, that didn’t even start coming around until the 90s. It’s a very new thing, mostly because doctors are very autonomous. They barely get along with themselves, much less someone else. They’re just not designed to play well with others, you know, we’re, you were particularly selective for your traits of OCD and high perfection, right? So all of us, all of us in dentistry, we’ve all got those characteristics. So you’re like, Alright, you’re high. You’re high OCD, you’re ADHD, you’re a perfectionist and now I want you to basically marry someone in your work life and then it implodes and you have 13 Associates in five years, right? So it’s just like, hard. It’s not, it’s not a good idea on any level and yet, and yet, I think those who pull it off, contribute more to the world and create more life balance and create the wealth. There’s really not going to be a lot of ways to overcome your student debt. Student debt is in my mind, hyper-inflated for the agenda and the agenda is white collar slavery. So if you have 500,000 in debt, and someone scares the shit out of you, then you will go and take a job that pays you 200 grand guaranteed versus believing podcasts that say, “No as a solopreneur you can take home 500 grand, 600 grand,” and you’re like, “No way, you’re from a foreign planet,” but it’s true. Chris, I love that there’s a real nugget here in distinction between because I think a lot of people would say “Gosh, garage door sounds really hard. I don’t know anything about construction. I don’t know anything about that, buying 100% sounds really risky because then it’s all on me, so I’m gonna dabble and do this buy in buy out,” but go back to the debt structure that after-tax personal loan versus pre-tax business loan, what’s the net-net on that, say it’s a million-dollar practice?

Chris Sands 19:51
Just want a clarification. What you mean by net-net? Well like

Dr. Daniel Haws 19:56
You talking Chris’s language here, he’s

Victoria Peterson 19:58
Yeah, yeah. What’s it difference in in my, my personal take on mine because I gotta pay one after my taxes, I gotta pay the other loan,

Chris Sands 20:06
I’ll put it this, I’ll put it this way. You know, when you buy a practice outright, and you take that loan, that loan is inside your business and you’re paying that loan with your business, revenues, your business cash flows, and but in all cases, people don’t realize this all debt is paid off with after-tax dollars. All debt is paid off with after-tax dollars, the only thing you get to deduct is interest. Okay, you get depreciation on things like equipment, assets, and goodwill over time, but the debt payment itself, technically is all the principal portion, is all paid off with after-tax dollars. So it’s just easier when it’s inside the business, you’re using the business money, it’s always easier to write a business check using the business money to make the loan payment, but when you buy in partially, you know, your, when you buy and you take a loan out, that loan is your personal loan to bring cash to the table to buy in. That cash is then given to those existing, the existing partner or partners and they’re going to be required, typically by their debt covenants to pay off their debts with any any kind of portion sale anyway, but their debts are not your debts, when you buy in that portion, your debt is that personal loan you took out to buy in. So it just definitely, you know, hurts more, it feels like it hurts more, when you have to, you have to take the money home, withhold taxes, you know, set aside taxes, and then you’ve got to make that loan payment personally, when you are a 30% partner or 50% partner, you know that is just your personal loan to buy in. If later on down the road, you buy out the remaining partner in full, the remaining interest, then all of those loans can be combined and put inside the business for you and you’d pay it with the business cash flow. So you know, debt has a I like to say the debt has, the byproduct is phantom tax. When it’s, even when it’s in the business, the business owner doesn’t even realize that when the payment is five grand, the cash flow required for that debt is not only the five grand, it’s the five grand let’s say that the principal portion is three grand, you owe 40% tax on that three grand that’s 1200 bucks. So the cash flow required for that $ 5,000-month loan is really about $6,200 a month and you don’t pay it that way, nobody does, but that’s where people sometimes are like, “How can I owe this and tax it’s not in my bank account, I didn’t take it home?” A lot of times that’s as a result of there being a lot of,

Victoria Peterson 22:39
You just solve the biggest Scooby Doo Mystery Of Finance ever.

Chris Sands 22:47
Yes, I get told that a lot.

Victoria Peterson 22:48
I want to get into the mystery van and get Thelma and Louise on that one again. So yes, oh, I don’t know about the three of you, but I want to continue doing podcast with the three of us on this one, I’m gonna round it out, going back to Joanne, this was so such great stuff, I know we got 5000 other things we can say, “Joanne, I’m a young doctor, I know what I’m looking for as an associate, I want to hit my milestones of 83,000 a month, I’m going to get in there, I’m going to make sure my one chair is producing 40 grand so I can get that second chair and become the producer and all of those things. Now I’m thinking about buying in and I’m going to be a partner,” and one of the things that you and I talk about a lot at Productive Dentist Academy is sitting down and taking the time to create a memorandum of understanding an MOU. Who does what and this isn’t about voting rights and things like that. It’s about skill sets and talent. So talk about some of the really cool things you can do to set a partnership or an associateship up for success.

Joanne Miles 23:56
Yeah, and, you know, a lot of it is you kind of see, I unfortunately get to see all the errors along the way. No to do the other way, but yes, I think it’s it’s it’s almost like I’m a business contract,it’s a marriage contracts. In a sense, there’s a you, you have to have an understanding of how are we entering into this agreement and, and that agreement also has to have some kind of a clause of how we would exit this agreement.

Victoria Peterson 24:30
You got to have the prenup.

Joanne Miles 24:34
You gotta have the prenup. Those are like the two big big pillars and then there’s all this stuff in between. That’s the life, right? And I you know, you want to try to make it as far as running the business, there needs to be a co-leadership. There has to be, it’s a mom and dad and then your team is the children and you can’t be divided you know and so there has to be agreements along the way of how are we going to be how are we going to lead this team. Who has, who’s more of the extrovert, and is more, is better at building relationships with the team, maybe they take more of the lead and then the other person is more the administrator, and is great at at just dealing with a lot of the

Victoria Peterson 25:22
Book-keeping camping equipment and lab vendors, and,

Joanne Miles 25:26
Right. You know, and who’s really great at mentoring, versus who has like, hardly a fuse of patients left and you know, in them. You know, so it can be many things like that, it’s who’s going to be on call, and when, you know, they don’t think about this, it’s like, well, I always want to take Christmas off, or will my kids, you know, you don’t have kids right now, maybe someone’s younger, and I have kids, so I’m always gonna take spring break off, but then all of a sudden, one day, that person now has children, there has to be some compromise in there. These are the things that unfortunately, don’t get discussed early in the stages. It’s, that can trip you up and then there’s, I’m going to say that there’s these core values and core beliefs that have to be discussed. If you cannot see eye to eye on how you’re going to conduct yourself as a human being and there are some true conflicts of what one person might think is not a proper way to conduct yourself with your team, and the other person is a little bit more loosey goosey, that’s another area and when you are in a partnership, you are both at risk and, and so it’s very important that you talk about the risk management side of things and what your what your deal breakers are. I have seen situations where one partner had, you know, we’ll just say a lot of integrity in areas and the other one did not and got caught with the hand of the cookie jar, but it came down it trickled down into the team and it could have been an enormous disrupt for the business. So there’s a lot there.

Victoria Peterson 27:21
It doesn’t even have to be I love what you’re pointing out like the big value, like value integrity pieces there, but it’s even the focus, right? You and I were talking about this the other day of, do you believe in sharing profits with the team? That can be a very polarizing conversation, you’re like, “Well, of course, we have an incentive plan for our team. What do you mean that you don’t agree with that right now?” So yeah, we’ve got a very detailed document that we walked doctors through, as personal counselors to, you know, each person fills it out on their own by themselves and then they send it to Joanne and she looks at it and kind of puts it in collates it into one document and says, “Here’s where we’ve got some good alignment, here’s where we’ve got some gaps, here’s an area that we really might want to look for, for some of these deal breakers and somebody’s going to have to give.” it takes time and it’s it’s unfortunate that we move at such a pace that we don’t always take that time. It’s not doing these things to set yourself up for success not only causes heartache and stomach lining, it costs you a lot at the bank account too.

Dr. Daniel Haws 28:34
And at the same time, you can’t you can’t enumerate every detail. You don’t I mean, you can’t enumerate the spring break thing that someone’s going to have, but when I do have is and this is gonna happen. I mean, there’s not enough pieces of paper out there. I think the reality of it is is do you get along and what did they say the most success most? The best indicator for successful marriage is probably going to be the best indicator for also a partnership or something like that is how do you communicate when you disagree and how, what is your ability to, are you, are you bullies? Are you me? Are you angry? Do you hold grudges for the rest of the week? Well, goodness, no staff is gonna want to be involved with that, you know, or are you able to work through that together? I think that for me is key. Of course, so many of those things. I was like, yes, yes, yes, yes, yes, yes. Have all those, make sure those are all signed and dotted and everything.

Victoria Peterson 29:31
Thank you all three. This is, these last two episodes have absolutely been some of the most fun episodes I’ve recorded over the last couple of years. I hope that you come back and we play again together sometime. I look forward to it. Chris. If people want to get a hold of you, what’s the best way for them to reach out?

Chris Sands 29:51
You can check out our website at profi2020.com, p r o f i 2 0 2 0.com and we’re on basically all forms of Social media. We take messages all the time through those, so please feel free to look us up. Give us a follow.

Victoria Peterson 30:07
I love it. Joanne of course you’re here at Productive Dentist Academy but if anybody wants to reach out what’s the best way for them to do that?

Joanne Miles 30:13
Would be via email at joannemiles@productivedentist.com

Victoria Peterson 30:22
I love it, and Dr. Daniel, if you’re hundreds and hundreds of new young dentist fans want to get a hold of you and send you gift baskets. Any Do you have a way for them to reach out?

Dr. Daniel Haws 30:36
Yeah, just danhawes@gmail.com.

Victoria Peterson 30:39
Love it. I love it. Thank you all for being here today.

Joanne Miles 30:42
Thanks.

Chris Sands 30:44
Thank you.