Dental Practice Heroes

Why Are DSO's Failing? What's Happening Inside Dentistry with Jake Berry

• Paul Etchison, Jake Berry • Season 3 • Episode 86

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Why have dozens of DSOs collapsed? What’s the impact on the dental industry? And how can you protect yourself, even if you never plan to sell? Tune in to learn what’s really happening in the DSO market, and what YOU should look for if you're considering a DSO!

Topics discussed in this episode:

  • Why so many DSOs are failing
  • What investors look for in DSOs today
  • 3 characteristics of an ideal partner
  • Risks of the DSO business model
  • Benefits of partnering with a DSO

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Paul Etchison:

You might not be thinking about selling your dental practice.

Paul Etchison:

In fact, you might be totally against the idea. But here's the thing. What's happening in the DSO space right now is reshaping the entire future of dentistry. Practices are being bought, flipped over, leveraged and even, in some cases, abandoned. In this episode, I sit down with Jake Berry, the chief development officer of MB2, one of the few DSOs that's not just surviving but thriving in this environment, and we're pulling back the curtain on what's really happening behind the scenes in the industry. Why have dozens of DSOs gone belly up and what are investors looking for right now, and how does this affect every practice owner, whether you're a solo group or just starting to think about your long game? If you want to understand where dentistry is headed and how to protect your future, even if you never sell, this is an episode you don't want to miss. You are listening to Dental Practice Heroes, where we help you to create a team and system-driven dental practice, one that allows you to practice less and make more money.

Paul Etchison:

I'm Dr Paul Etcheson, a dental coach, author of two books on dental practice management and the owner of a five-doctor practice in the south suburbs of Chicago. I want to show you how being intentional about ownership can create a practice that supports your life instead of consuming it. So if you're ready to create a true business that runs without you, you're in the right place. Let's get started. Hi there, welcome to the Dental Practice Heroes podcast. I'm your host, dr Paul Etcheson, and going a little special direction here today. We're often talking about practice ownership or talking about associate-driven practices and you hear me talk about MB2. Often is the partnership that a DSO that I partnership with. But I've got somebody on here that I very much respect and has helped me over the years to understand more about the DSO environment and market and landscape, and dude's just a wealth of knowledge. We were talking the other day and I said, dude, I got to get you to come on. So we've got the chief development officer at MB2, jake Berry. What's happening, jake? Welcome to the podcast.

Jake Berry:

Hey, dr Etchison, good to see you. Thank you for having me on.

Paul Etchison:

Dude, love having you on.

Paul Etchison:

I mean I'm surprised we haven't done this before, because you know, every time there's been times I may have been on other people's podcasts as like some sort of expert in the DSO landscape and I may have reached out to Jake before I was interviewed on that podcast.

Paul Etchison:

It may have happened I'm not going to admit to it, but it just may. But yeah, man, we've heard so much has happened in the past five years with the DSO landscape and there's a lot of misconceptions in it. There's a lot of anger I mean, there's a lot of anger about this happening to dentistry and I think it's just all helped by information. But what I want to talk about first is that maybe five, 10 years ago it seemed like if you bunched up practices you were able to sell them for a lot more money. All you had to do is just put them together on paper and I think what we've seen in the past two years has really shown that that's not true. Talk about what was happening a few years ago and what it kind of looks like now, how that contrasts.

Jake Berry:

Yeah, it's a good observation and a good call out on the space. Really, there was a big surge of DSOs that were created in 2019, 2020, maybe 2018. A lot of capital, institutional capital that put a lot of big dollars behind startup platforms, and their investment thesis was we will go acquire 40, 80, 120 dental practices and then we're going to turn around and sell them to the next investor and collect on the spread. It was just a very simple the finance term is actually called arbitrage and the concept was the DSO buys dental practices at six or seven times EBITDA which is a fancy accounting term for earnings and turn around and sell them for 12 or 13 times earnings and capitalize on the difference. It was a very, very I don't want to say amateurish, but just a very basic way to try to create value for shareholders, and that strategy works in a low interest rate environment. It works in a low interest rate environment. It works well when private equity is able to raise a lot of dollars through their fundraising, when the risk environment is low and when there's ready and willing participants on both sides of a transaction.

Jake Berry:

Well, covid really exacerbated a lot of transaction activity between doctors and DSOs, for a couple of reasons, I think.

Jake Berry:

First, dentists realized how hard operating and owning a dental practice is, especially in an environment like that, and secondly, they realized the valuations from these DSOs were a lot higher than the 70 to 80 percent of collections formula that's been around forever, and so a lot of activity drove valuations to a very attractive place for dentists and a lot of these DSOs.

Jake Berry:

I would say they acquired too many practices, really weren't able to integrate them or operate them and they overpaid for those practices. And what's happened really starting end of 2022, going into 2023, is the private credit markets seized up, the debt that was available to fund these types of acquisition strategies dried up. It was available to fund these types of acquisition strategies dried up. Interest rates went way up, then you had inflationary pressures on labor and it just led to a very bad situation now in which what was thought of as a very attractive and easy strategy has now turned into a very difficult landscape, with now over 150 capital-backed DSOs out there. For your average listener, who's maybe trying to understand what's been going on, it's a simple market dynamic of doctors realizing they can sell their practices to a private equity-backed DSO for a much higher valuation than they originally thought the problem is on the back end. These DSOs that have deployed and invested that capital to do that are now kind of stuck with their investments.

Paul Etchison:

And I think what's worth pointing out is that a lot of these transactions would be some cash up front but then maybe some stock options in the company which work when these companies go to market and get a new private equity backer. That's going to then do with that arbitrage thing. And you know, I see what's on Facebook. I see people there's a lot of like, hate to the DSOs. Oh, they're just all making stuff up. They're telling, they're telling you lies. And I used to jump on there and say hey, hey back, hold on a second, Hold on a second. I'm really happy with partnering with MB2. But talk about how many company, how many DSOs went completely belly up where they go and they say, hey, we want to sell and get a new person, come in new investors, we have this great investment, come buy into it. And everyone's like no, don't like that investment, pass no good.

Jake Berry:

No, don't like that. Investment Pass, no good. Yeah, you know, I was at Henry Schein's Thrive Live conference last week and there was an industry expert on a panel talking about the transaction activity that's taken place in the DSO space over the last really since mid to late 2022. And the statistic that he threw out and I think he's probably right it kind of matches with what we track is that four dozen DSOs so almost 50 DSOs have gone to market to find that outcome you just talked about, and no investor was willing to step up and buy the company or invest in the company or recapitalize the company. That's a really tough spot to be in to recapitalize the company. That's a really tough spot to be in. The flip side of that coin is that seven groups have gone to market and received some sort of successful outcome. So you know that data is probably pretty close to being accurate. A lot of this stuff doesn't get splashed up on the front page of the Wall Street Journal, so it's closely guarded information. But that's not a good statistic. When 60 groups go to market and only seven of them get a good outcome, that's really not a good look for the space.

Jake Berry:

And then you asked about even worse situations where companies have had to you know, basically turn the equity over to the lender. I've heard varying statistics on this. I think probably one of the more reliable stats I've heard is there are now upwards of 30 different DSOs in receivership, meaning the lender has taken over ownership of the company. That's kind of like for everyone who's bought a house. That's like your home mortgage lender foreclosing on the house. Not a good outcome.

Jake Berry:

But listen, all the headwinds that many of your listeners face in running their own practices privately. Dsos face those same headwinds the rising cost of labor, the inflation of the various inputs into doing dentistry, real estate costs and rent going up pressures on the fee schedules, patient volumes Whether you're a DSO or a private practitioner, all these operational challenges are very real. And I'll go back to my original point. If a DSO was not constructed to actually own and operate and add value to their practices over the long term, if it was just intended to be a quick flip, they're not really in a good spot to add value and operate efficiently, in a good spot to add value and operate efficiently in a tough market, and that's what's led to some of those really bad outcomes.

Paul Etchison:

What I hear you saying is that running a DSO is much like running a business there's profits and there's, you know, there's expenses, and just because you acquire a bunch of practices doesn't mean it's profitable. That's right. What would you say for these groups that went to market and all the investors said nope, not interested, and essentially all these people, these doctors that have stock in this company? They were promised a lot of things they're not getting. Like what do they want to see out of a DSO?

Jake Berry:

Yeah, I think, fundamentally, the first thing they want to see is a really strong alignment model with the doctors. So you know, we were in market for a lot of 2024, as you know, and we were meeting with really some of the largest private equity funds in the world and one of the heads of North American healthcare for one of the largest investment groups in the world, and you would think he would want to focus on the numbers and growth rates and things like that. You know what his question was. You know what he went to. He said how do you make the lives of your doctors better? Tell me that. Tell me how MB2 makes the lives of their doctors better. So I know that this is a long-term sustainable partnership model, and we heard that for the first time and thought, okay, that's a really good, insightful question, and we answered it. But you know what it came up with the next investor and the next investor and the next one after that.

Jake Berry:

And so I think what investors want to know is that any DSO is not just made up of a bunch of doctors who wanted to sell into this dream and make a bunch of money on stock and then exit. They want to know if they put a lot of money behind the business, that they're going to be aligned with those doctors long-term. So alignment model, first and foremost, is really what they're looking for. And then they get into the fundamentals of the business. They want to know that a DSO can grow organically, not just inorganically. And what I mean by that is most DSOs have been very, very focused on acquiring as many dental practices as they could. That is one way to grow, but I will tell you that investors place a premium on businesses that can grow without having to do that. And so, just as you've had to focus on growing your practice through trying to cut costs or improve fee schedules or offer more services, add more value to their patients, we've had to think of the same thing.

Jake Berry:

And so if a DSO can't really demonstrate that they can do that consistently and that their sole means of growth is to go out and acquire more dental practices, that's a really tough position to be in with investors. And then I think, lastly, what they're really looking at is any investor wants to know that the leadership team is committed to the long-term success of the business, that they also have financially aligned incentives. They're not going anywhere. I always like to say MB2's leadership team is pretty battle-tested. We've all been together for many years. I mean, you've met Dr V. This started, you know, really out of his sole private practice back in 2007. So I think any DSO that met a cold reception in market really has to think of the commitment of their leadership team, how they're going to drive consistent growth outside of just acquisitions, and do they have the right alignment model with their doctors?

Paul Etchison:

One thing I think that's worth pointing out is that MB2, we just had this recapped event that happened. It was a January, February.

Jake Berry:

Technically close to November. Yeah, it's been a minute. Right, it's November. Wait, okay, it was.

Paul Etchison:

November. Yeah, like it's been a little bit, but we had this. I remember like you guys were keeping us practice owners in the loop. And one thing I remembered Justin Puckett I believe he is the president. Yeah, justin Puckett, one thing that they said is that you were getting further in talks with a certain group, but you guys weren't necessarily sure if they were the right alignment model for MB2. Because not only is it about dollars, it's about control, and I know that MB2 is very big on autonomy of their owner doctors. Could you speak to that, as that is not only just you selling yourself to investors, but you finding the correct investor for the group to going forward?

Jake Berry:

Yeah, it's really a two-way decision. The question for us always was where are we most aligned to find a set of investors that understands the values that Dr V has laid out for MB2 and the values that all of our doctor partners hold near and dear? And, as you know, the thing we've really put on a pedestal is the autonomy of our doctors. We don't want to tell our doctors how to run their practice. We want to offer up a lot of advice and operational support to make them a better version of themselves, but certainly not tell them how to do things, and so we wanted to make sure that any investor we picked was going to be aligned with that first and foremost.

Jake Berry:

I think too many investors, too many DSOs, have a very short-term vision, and I think you've been with the group for a while. A lot of our partners have been with the group for 10, 12, 15 years. No one's looking to get to a really flashy outcome. And then the end. So we had to think of the set of deal terms that we accepted in this particular deal. We wanted it to set us up for success for the next three years and then the next six years, and so oftentimes, if you get too greedy on what you're going after, it's just really going to limit your optionality and future financial success. And I think what Dr V's always wanted to stay committed to, and what our leadership team has wanted to stay committed to, is that this is going to be a good outcome for our partners today. But you know what? We're going to have another good outcome in three or four years and then we'll try to get to another good outcome three or four years after that. So this doesn't become kind of a one and done machine.

Paul Etchison:

I think this is one of the things that makes them be too great. I mean the autonomy and there is alignment with doctors, but talk about your selectivity that you guys use when evaluating practices to join the group, because it's not just anybody.

Jake Berry:

Yeah, yeah, that's right we talk to in any given year. We talk to somewhere between 2,200 and 2,500 dentists a year. That's a lot of doctors we talk to. Some of those conversations don't move past the first conversation. Some go all the way through to close. We make about 400 proposals a year and we close on about 100 every year.

Jake Berry:

So from first conversation to what we actually acquire, there's a lot of selection and discernment that goes into that from our side and the doctor's side as well. And I always try to draw three circles. The first is the business has to be a quality business. It has to be a practice that kind of fits. What we're looking for has strong metrics and we're confident that that will be a long-term good investment. The second circle we draw is there has to be a good fit with the doctor, a good partnership fit. We see a lot of doctors who are really, really good, successful practice owners but candidly, it's not a personality that we want to work with long-term. And then the third circle is can we make the deal terms work for us and for the doctor? And where those three circles intersect, that's where you have a deal.

Jake Berry:

And so what we have tried to be very, very selective on is let's make sure we invest in really good practices and let's try to bring on the best partners, who we know are going to be a good cultural fit, who are going to be easy to work with, who we can collaborate with.

Jake Berry:

I think, as you know, this is like a marriage you can put whatever you want in a contract, but contracts only go so far in the day-to-day of governing a partnership, and so we want to make sure that we really have a shared alignment of vision in how to grow our partner practices and we want them to feel aligned with the rest of our partners and the growth of MB2.

Jake Berry:

So historically, it's been about a 3% selection rate. I think there's been a lot of hubbub about the DSOs are taking over and the dental space is being overrun with DSOs. I will grant that there is a lot of DSO activity, a lot more than there has been, but the data we pulled there are 136,000 dental practices in the US. There are 136,000 dental practices in the US. If you take the 150 DSOs, 150-ish DSOs that are backed by capital, I mean like starting from Heartland at the top all the way down to your 20, 30 location DSOs, that's only about 16,000 practice locations, so there is a lot of private practice ownership that still exists. Sure, there are some reasons that the DSO penetration is increasing, but by and large, dso market share is still very small.

Paul Etchison:

Yeah, and you know, I think it's interesting to hear you say that, because I know somebody personally and I don't know him very well, but he said he was talking with MB2 and he said, dude, like, he's like I got a great practice and I didn't realize I was also being interviewed and I said what do you mean? He's like they just didn't want to do it anymore and I think you guys had told them that. You know it's just not right in alignment, but it's interesting that you would like a lot of people get the impression that it's all about dollars and cents and you're just buying any EBITDA you can and just putting it all together. And I think that's probably what screwed over so many different groups in the past decade. Is that that's what they were going with, that kind of model. What do you think is one of the harshest realities of the DSO space that nobody knows about? This is going to be a little bit of a technical answer space that nobody knows about.

Jake Berry:

This is going to be a little bit of a technical answer, but I think it's an important one. Dsos, like any private equity-backed business, are highly levered businesses, meaning they operate with a lot of debt on their balance sheet. That's just the strategy. That's why it's called a leveraged buyout. The risk tolerance for DSOs is just razor thin. They do not have a big margin for error, and what I mean by that is a declining business. Even if it's 1% or 2% puts a DSO in a really tough position, because when that starts to happen, the smart money that backs these companies sees that and then they get alligator arms on how much more capital they want to put into the business.

Jake Berry:

You know, I'm sure a ton of your listeners. They've had up years, they've had down years and you know what, when you own your own business, that's fine. You may be up 20% one year, down 5% the next. You know, in the year after that you're back up 10% again, and the only thing that it impacts is your take-home income as a private practice owner. Again, and the only thing that it impacts is your take-home income as a private practice owner. Well, as a DSO with a highly levered balance sheet. If your earnings drop two or 3%, that can really be catastrophic and put you into default. They do not have the luxury of just kind of having a down year and oh well, we'll get it on, we'll do better next year. There's just a lot of pressure to continue to operate a business in a very sustainable way.

Paul Etchison:

Yeah, it almost makes me think of real estate. There's something called a DSCR and I don't know if this is something that comes up in the DSO space, but it's debt service coverage ratio and that's essentially saying, for an apartment building, how much of the income is coming in relative to what the principal and interest is on the loan. Is it also the same in the DSO space?

Jake Berry:

It's exactly the same, it's a similar ratio. It's called the leverage ratio and that's simply a ratio of total debt over total EBITDA, which is the earnings of the business. It is that early warning indicator that something is going wrong in the business if that leverage ratio is increasing. And I think the uncomfortable truth in the DSO space over the last five or six years is many DSOs they bought good practices. They really did. There's nothing wrong with the practice good doctors, good fundamentals on the business but when you overpay for those practices and then you're faced with a higher interest rate environment, that can really put a lot of pressure on your ability to service your debt and on your balance sheet. So the practices continue to be fine, but it doesn't mean that the parent company's balance sheet is in a good spot.

Paul Etchison:

Yeah, it's definitely a much more complicated space than it seemed, especially even like when I got into it. You know these. I've learned so much about it my past five years in partnership. It's just, it's another business and for the arbitrage we talked about, a new investor has to come in, see potential value increase and want to pay money for it. Talk about MB2 and the same store growth and how that plays into the investor returns, which makes it something investors want to be part of.

Jake Berry:

Yeah, so we've pretty consistently been able to demonstrate 5% same store revenue growth and, you know, three and a half to 4% same store earnings growth across all of our vintages. So you know we've been aggressively acquiring dental practices really since 2017. And what a lot of DSOs like to advertise is that they have really high same-store growth. But that number is a little bit misleading because so much of their growth has just recently occurred. They're kind of riding that year one improvement that they get on the practices that they just acquired.

Jake Berry:

The real test, the real proof on if you can grow sustainably and show consistent same-store growth is can you do it with the practice you bought six months ago? Can you do it with the practice you bought two years ago? Can you do it with the practice that you opened eight years ago? And so one of the things that I think helped us in our marketing process and investors understood was that same store growth was consistent across our 2017 vintage, 2018 vintage, 2019 vintage and so on and so forth, and so we gave investors some comfort. That are the operational resources we have and the ability to leverage our scale to improve you know whether it's pricing power or, you know, leverage procurement to help our partners has an impact. But, most importantly, the alignment model with our doctors makes them every bit as incentivized to continue to grow their business, just like your own listeners do in private practice. Like our partners don't think any differently than a private practitioner. It's not like their mindset changes once they partner with MB2. They still want to take care of their patients, they still want to grow their business, they still need to take care of their teams, and so the alignment model and having them keep equity in their practice helps preserve the ability to grow on an organic basis, year over year over year.

Paul Etchison:

You know you mentioned the year one improvements, just so, like listeners might understand, like what that? Why is that different from a year two improvement? What can somebody joining a DSO typically expect to see in year one? Where do those improvements come from?

Jake Berry:

Yeah, I mean so I'll speak from our side. I certainly can't speak for every DSO, but generally speaking, we're saving our doctors a lot of money on supplies. There's a big cost savings there and that's because we have formularies with the same companies they're buying supplies from. We're just leveraging that purchasing power across 800 locations. We're able to save them money on labs. We get better cost savings on merchant services. We're able to reduce technology costs.

Jake Berry:

In one of our newer capabilities we have a payer strategy team that is very, very focused on helping drive higher fee schedules with the insurance companies. So whether it's the ability to recruit more doctors in faster and create more provider capacity, whether it's the ability to increase fee schedules or just cut costs, all of those things ultimately lead to more profitability. The issue is you see that big pop in year one when you kind of bring all that value to the table, but then it gets harder and harder, as that practice has been with the DSO for a longer period of time because then we are forced to continue to have to create value year after year and go back and get new cost savings or renegotiate additional cost savings or find new ways to help our partners grow their revenue.

Paul Etchison:

Yeah, so it speaks to the fundamentals of the group as a whole. Can they continue to grow? And that's something that MB2 has demonstrated, where a lot of the shorter term DSOs might not have the track record. Why has the MB2 model worked so well? What makes it special versus other people in the space?

Jake Berry:

I think there's three components to this people in the space. I think there's three components to this. The first is the actual alignment model itself, in that our doctors maintain practice level equity. I mean they are highly incentivized, just like I mentioned earlier, to ensure that their practices continue to be successful, that that mindset doesn't just leave. The second they become an MB2 partner. They want their patients taken care of, they want to see an MB2 partner, they want their patients taken care of, they want to see their business do well, they want to see their teams treated right.

Jake Berry:

And we've always told our doctors don't ever expect to sell 100% of your practice level equity. I think that expectation management on the front end has been very important to attracting the right doctors, the doctors who understand that they're always going to be an owner. Point number two is partner selection, and because there are other DSOs out there that have models similar to ours and, as we talked about a little earlier, we are very, very focused on trying to pick the right partners, because we do give our partners autonomy, both clinically and operationally, but that doesn't mean we want people who are going to be hands off the wheel. So we have to pick doctors who really want to make their practices better and want to embrace us as a partner in the business to achieve that. If someone's going to give us the Heisman and tell us to stay out of their practice, that's not a great partnership fit. And then the third I think this may sound a little silly but it is so true is just the way that we find ways to engage with our doctors personally on a regular basis.

Jake Berry:

As you know, we do owner's trips each year. As we've gotten bigger, we do dinners in different cities to try to bring our partners in certain cities together. I mean Dr V will fly out and personally do those. The rest of our executive team will fly out and do those. We'll just send random gifts. We send out Yeti coolers and swag to our partners just to thank them.

Jake Berry:

This is a people business and the closer relationships we can maintain with our doctors, the better we are, because it cuts off so many problems. If we're engaged with our doctors, the better we are because it cuts off so many problems. If we're engaged with our doctors, they're not going to let problems bubble under the surface and then resentment builds and then they're just unhappy and disgruntled. We want to be engaged with them so they'll pick up the phone and tell us that they're unhappy about something. Just like any good, partnerships should work, and the happier the doctors are, as you know, the better they're going to be, the happier and more engaged they're going to be in running their business, taking care of their patients and ensuring the best business outcomes.

Paul Etchison:

And I can say from my personal experience I have spoken to so many people in the C-suite that I mean via cell phone. You know it wasn't like I had to go through to get to them, it's just accessible and that's something I've always appreciated. And everybody I communicated with you guys out in Texas, it was just like talking to friends, it was like talking to normal people and I've heard that said with a number of people that I know that have also partnered up in the past few years. So you know, if you're a listener and you're saying like, hey, this doesn't sound so bad like what everybody's saying on the Facebook forums, Maybe this is something I should look into more.

Paul Etchison:

If you're interested in getting in touch with Jake, you can go ahead and text MB2 to the number 312-910-2603. That will be in the show notes. I'll also have a link somewhere where you can put your information in and you can get some more information. Someone will reach out to you and just take a look at your practice, just give you evaluation, give you an idea of where you're at. Maybe you're not ready for MB2, but maybe you want to find out what you need to do to get ready, if it's something you think you're going to do in your future? I found a question here, jake. If there's one thing you wish, just the general dental population of owners knew about MB2 dental, what would that be?

Jake Berry:

I think they just need to understand that this is not that different than a partnership with another doctor. So if you're a practice owner and you've ever contemplated a partnership with another doctor and all that goes into that, it's the same. It's just MB2 is not bringing a clinical skill set to the partnership or the practice. We're bringing some business acumen, but we are bringing an alignment of interest and a desire to make that business grow. And I think if people think we're kind of just like any other DSO or we're, you know, a big boogeyman, I think nothing could be further from the truth.

Jake Berry:

Dr Villanueva is the founder and CEO. He's a general dentist. He's not going anywhere. He's like 45 years old. I mean, he's not going to go be the CEO somewhere else and the leadership team has been in place for 10 years. We have very close relationships with all of our doctors and we're not going anywhere. And so I think to your point, it's at least worth the conversation and gaining some perspective on what a partnership could look like. But what doctors should understand about MB2 is we are definitely a people-driven organization and we fully understand and hold dear that the doctor partners are really the keys to success within our business.

Paul Etchison:

Yeah, I couldn't agree with you more, man, and from my experience that is totally true. He's not just saying that. So, hey, jake, thanks so much for coming on. I'd love to have you on, like maybe a year from now we could talk about the DSO industry again and see what's changing, because you and I both know things are changing. You know and got to adapt, just like any other business. But, man, I think you dropped a lot of good information today and I hope some doctors will reach out to you and find out more. Thanks so much for taking time out of your day to be with the listeners.

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