Love them or hate them, dental service organizations (DSOs) take up a lot of the conversation when it comes to selling a dental practice. In fact, there is so much ink being spilled over DSOs, you might be surprised that they are not quite as prevalent as you think. Regardless, they are having a significant impact on dental associate employment and dental practice transitions across the country. If you are considering a dental practice transition, you may need to consider a DSO as an option, but, if you don’t think that’s right for you, there are still plenty of private buyers out there. Here we discuss some of the things that you’ll need to think about if you are considering selling your dental practice to a DSO.
How Common are DSOs?
Not as common as you might think. According to DSO News, only about 16-20% of practices in the U.S. are “consolidated practices.” However, if you compare the dental industry to the larger medical industry, where consolidation of physician practices has been going on for quite a bit longer than DSOs have been consolidating dental practices, you can see where this might be headed. According to the American Medical Association, in 2016 the medical industry in the U.S. hit a new benchmark in which less than half of physicians owned their own practice.
This increasing trend is also shown in dentist employment statistics. As of 2017, the ADA reported that, overall, only 7.4% of all doctors were affiliated with a DSO. However, when you look at younger dentists, the number more than doubles to 16.3% among doctors aged 21-34. This disproportion between the number of new doctors joining DSOs and the number of doctors overall indicate a trend toward DSOs having an increasing presence in the field.
Anecdotally, however, there is evidence that young doctors associate with a DSO but don’t necessarily stay and work long-term in that employment model. After all, a young doctor is looking to get experience quickly and the compensation package offered by a DSO is likely be greater than what they can earn working for a doctor-owned practice. Those higher salaries are going to be attractive to recent grads who have, on average, $261,150 in student loans.
While this is making it harder for doctor-owned practices to attract young dental associates, this doesn’t mean that the younger doctors are necessarily forgoing ownership of their own practices. After all, there are significant financial incentives for owning your own practice. So while DSOs are certainly changing the landscape, they haven’t totally remade it.
Selling a Dental Practice to a DSO May Not Be as Easy as You Think
As with any dental practice transition, the best deal for your practice is going to depend on what you are looking to get out of the practice—whether you want to hand over the keys and walk away with pockets full of cash, whether you want to be rid of the business side of the practice but keep providing patient care for another 20 years, or are somewhere in between.
Because DSOs are have deeper pockets and easier access to financing than most individual buyers, they can often outbid the individual buyers. However, those big offers may not be all cash and can come with a lot of strings attached. No doubt you’ve received numerous emails and postcards urging you to consider joining your practice to a DSO. Note that they often do not say that you will sell your practice and work form the. They say things such as “affiliating you practice” and “partnering” with the DSO. While this indicates something like a legal partnership, it most certainly is not the case. The DSO will own your practice and you will be an employee (although possibly one with stock or stock options).
Also, rumors of high payouts by DSOs can be overstated. First, DSOs are looking for particular kinds of practices. If yours meets their criteria, they may be willing to pay a premium. If not, they may still make an offer, but it might not be as attractive as you would expect. Under those circumstances, you may be better off with an individual buyer.
Second, if you are selling a dental practice with the intention of getting cash at the close and walking away, a DSO is less likely to agree to those terms. A DSO may make an offer that is a combination of cash and stock and will likely want you to stay on for a minimum amount of time (as an employee) to facilitate the transition. They may make a part of what’s being offered dependant upon you being able to meet their production goals. How hands-on or hands-off they will be during the transition will vary. However, to be certain, you will be an employee helping the DSO to remake your practice into what they want it to be. Also, there have been reports of DSOs not being quite as doctor-friendly or flexible as they present themselves (in addition to reports of some questionable patient care practices).
What to Consider when Selling a Dental Practice to a DSO
As stated above, a DSO is unlikely to offer you a premium for your practice in an all cash deal where you collect your payment and go on your merry way. So, if you are considering selling your dental practice to a DSO, here are some things you may have to grapple with.
The sale price that you will be offered can be comprised of a few different parts:
- Cash at close: this is pretty straightforward— it’s the actual dollar amount put into your hand when the papers and signed and the sale is closed.
- Earn out: this is money that you might get at the end of a multi-year employment commitment and is based on financial goals set for the practice. If you meet certain goals, you get a certain amount. If you don’t, then you mostly likely won’t get most, or possibly any, of the earn out amount. This allows the DSO to make a higher offer but end up saving some of that cost if your practice fails to perform with sufficient profitability from the DSOs perspective.
- Equity roll: this is where you have the option to take some of your cash at close and invest it in the DSO’s parent company. This is not always an option. However, when it is, the idea is that the buyer is a successful company that’s good at getting a return on its investments and you may be able to take the proceeds of the sale of a dental practice and turn it into even more money down the road.
The other major aspect to think about is becoming an employee of the DSO. This is definitely something to look at closely and carefully consider if an earn out is part of the deal. Some DSOs will negotiate some terms of employment, some will not. Regardless, you need to look at:
- Clinical compensation rate: is it based on collections or production? What about lab costs?
- Overall benefits package: does it include health insurance, malpractice insurance, a retirement savings plan, does the employer match any contributions for retirement, do they pay for continuing education?
- Non-compete agreement: how big of a geographical area and for how many years? Be sure to have a qualified attorney review the terms.
- Ownership: are you being bought by a public or private corporation? If you are being offered stock, what are you getting stock in?
Whether selling a dental practice to a DSO is the right choice for you is ultimately dependant upon the goals you have for your practice’s transition. At DDSmatch Southwest, our dental practice transition specialists work with you to help you define those goals and then use those goals to help identify a buyer with the right skill set and personality match to carry on your practice and the legacy you have worked so hard to build, whether it be a DSO or an individual buyer. If you are considering transitioning your practice in the next five years, contact us today for your free, no-obligation Practice Transition Assessment.