Dental and Medical Counsel Blog

At Dental & Medical Counsel, we understand that selling your dental practice is a significant step in your career. Deciding to sell to a Dental Support Organization (DSO) can bring both opportunities and challenges. This comprehensive guide is designed to navigate the intricacies of selling to a DSO, ensuring you make informed decisions. Let's delve into what selling a dental practice to a DSO entails and how to approach it effectively.

What Does It Mean To Sell Your Dental Practice to a DSO?

Selling your dental practice to a DSO means transitioning the management and operational responsibilities to an organization that supports dental practices through centralized services. This shift can help optimize your practice’s efficiency and profitability. It’s a decision that could transform your business operations and professional life, allowing for more focus on patient care rather than administrative duties.

What Is a DSO?

A DSO, or Dental Support Organization, provides management and operational support to dental practices. These organizations help with everything from marketing and finance to human resources and purchasing. By aligning with a DSO, dentists can alleviate the burden of business operations and concentrate more on clinical work.

The Benefits of Selling Your Dental Practice To a DSO

• Enhanced Operational Efficiency: Dentists can streamline administrative tasks with a DSO affiliation, improving practice efficiency. This setup allows dentists to focus more on patient care and less on the nuances of business operations.
• Financial Growth: Partnering with a DSO can improve your practice's financial health through improved billing, dental collections, and overall financial management.
• Access to Advanced Technology: DSOs often have more capital to invest in the latest dental technology, providing your practice with advanced tools without the upfront costs.
• Professional Management Support: DSOs bring professional management expertise, which can be invaluable in expanding your practice and improving patient services.
• Marketing and Patient Acquisition: DSOs can use specialized marketing teams to attract new patients more efficiently, increasing your practice’s growth potential and visibility in the community.

Evaluating Unsolicited Offers from DSOs

When considering the sale of your dental practice, it’s crucial not to jump at the first offer from a DSO. Evaluating all your options can ensure that you receive the best deal possible. Creating a competitive environment can lead to higher offers and better contract terms.

Fostering competition among potential buyers highlights the value of your practice, potentially leading to better offers. This strategy can be particularly effective in highlighting your practice’s strengths and unique qualities, making it a more attractive acquisition.

How to Create Competitive Bidding for Your Dental Practice

• Market the Unique Aspects of Your Practice: To attract more DSOs, emphasize unique aspects such as specialized services, location, or patient demographics.
• Use a Professional Broker: Brokers can help reach multiple potential buyers and create a bidding environment.
• Prepare Detailed Financial Reports: Clear and comprehensive financials can attract more serious offers from DSOs.
• Highlight Operational Efficiencies: Showcase systems and processes that are above industry standards.
• Demonstrate Strong Patient Loyalty: A loyal patient base is a huge asset, making your practice more desirable.
• Show Growth Potential: Future growth projections can make your practice a more compelling investment.
• Engage Multiple DSOs Simultaneously: Don’t limit your options; discuss with several DSOs to foster competition.

Selecting the Right DSO Partner

Choosing the right DSO is critical as it impacts your team, patients, and professional legacy. It’s important to find a DSO whose goals align with your vision for the practice’s future and who values the foundation you’ve built. Selecting the right partner can help maintain the practice's ethos and ensure its growth and sustainability. Carefully evaluate each potential DSO's track record and plans for integrating your practice into their network.

Assessing Cultural and Operational Fit with a DSO

Consider a DSO’s culture and whether it complements your practice’s ethos. Assess how they handle transitions and integrate new practices. Look at other practices they have acquired to understand their approach and the outcomes of those post-sale transitions. Ensuring a good fit can greatly influence your practice's continued success. This alignment is crucial, as it affects the day-to-day operations and the long-term satisfaction of your staff and patients. While practice management software can remove redundancies and improve efficiency, the software used could impact the transition as well.

Key Questions to Ask Before Partnering with a DSO

• What is your vision for my practice post-acquisition? Understanding a DSO’s vision for your practice ensures alignment with your expectations.
• Can I speak with other dentists who have sold to you? Insights from peers can highlight potential challenges and benefits. It can also yield insights into how dental benefits packages might change during the transition.
• What changes will be made to the staffing and operational procedures? Knowing this helps you understand how your practice will evolve under new management. You should ask about dental staff compensation after the sale as well.
• How will my clinical autonomy be affected? This question is crucial for maintaining your medical and ethical standards.
• What is the expected transition period, and what support will you provide? A clear transition plan is essential for a smooth changeover.

Understanding the Financial Aspects of DSO Partnerships

When engaging in a partnership with a DSO, one crucial financial metric to understand is EBITDA, which stands for Earnings Before Interest, Taxes, Depreciation, and Amortization. This measure provides a clear view of the practice's operational profitability by excluding the effects of financing and accounting decisions. DSOs often use EBITDA to assess the financial health of a practice, as it shows the cash generated from day-to-day operations that could be used to pay off acquired debt. Knowing this figure is essential, as it is typically a major factor in determining the valuation of a dental practice in the eyes of a DSO.

To calculate EBITDA for a dental practice, start with the net income, then add interest, taxes, depreciation, and amortization. For example, if a practice has a net income of $500,000, interest expenses of $20,000, taxes of $100,000, depreciation of $50,000, and amortization of $30,000, the EBITDA would be calculated as follows: $500,000 + $20,000 + $100,000 + $50,000 + $30,000 = $700,000. 

This figure helps DSOs evaluate the practice's profitability independent of non-operating factors and tax-management strategies. Understanding this calculation and its implications can significantly influence the negotiations and final terms of a sale to a DSO.

Understanding the Finances Further: The Value of EV / EBITDA

EV / EBITDA is a financial ratio that stands for Enterprise Value divided by Earnings Before Interest, Taxes, Depreciation, and Amortization. It's a commonly used valuation metric in finance, particularly when assessing the value of companies, including those within the healthcare and dental industries.

What is Enterprise Value (EV)?

Enterprise Value (EV) is a measure of a company's total value, often considered a more comprehensive alternative to equity market capitalization. It includes the market capitalization of a company, but also short-term and long-term debt as well as any cash on the company's balance sheet. Specifically, it's calculated as:

EV = Market Capitalization  + Total Debt − Cash and Cash Equivalents

Importance of the EV/EBITDA Ratio

1. Valuation Tool: EV/EBITDA is used as a valuation tool to compare the value of a company, debt included, to the company's cash earnings less non-cash expenses. It's a useful metric for potential investors to determine whether a practice is undervalued or overvalued compared to its peers.
2. Debt Factor: Since EV includes debt, the EV/EBITDA ratio provides a clear picture of the economic worth of a company more accurately than just using market capitalization. This is important in sectors where companies tend to operate with higher levels of debt.
3. Simplicity and Effectiveness: The ratio is simple to calculate and provides a quick snapshot of a company’s valuation and ability to pay off debt using its earnings before interest, taxes, depreciation, and amortization. It's effective for comparing companies within the same industry where they may have similar capital structures and depreciation policies.

Example Calculation of EV / EBITDA

To calculate the EV / EBITDA ratio for our dental practice example, we first need to determine the practice's Enterprise Value (EV). Let's assume some additional financial metrics for our example to help calculate this:

• Market Capitalization: This can be challenging for private practices as they are not publicly traded, but for our example, let's assume an estimated market value of the practice (or the price it might sell for) is $1,000,000.
• Total Debt: Suppose the practice has $200,000 in debt.
• Cash and Cash Equivalents: Assume the practice has $50,000 in cash.

EV = Market Capitalization + Total Debt − Cash and Cash Equivalents

EV = 1,000,000 + 200,000 − 50,000 = 1,150,000

We previously calculated the EBITDA to be $700,000. Now, we can calculate the EV/EBITDA:

EV / EBITDA = 1,150,000 / 700,000 = 1.64

Importance of Professional Representation During the Sale

Having professional advisors and a specialized dental attorney by your side during the sale of your practice to a DSO is indispensable. These professionals understand the complexities of such transactions and can guide you through the legal, financial, and strategic considerations. They ensure that all aspects of the deal are handled correctly, protecting your interests and helping to maximize the value of your sale. Moreover, experienced advisors can foresee potential pitfalls and negotiate effectively on your behalf, which is crucial in achieving a favorable outcome.

Dental attorneys and advisors bring a level of expertise that is essential for navigating the regulatory environment of dental practice sales. They can clarify the implications of each clause in the contract and help you understand the long-term impacts of the sale agreement. Their guidance is particularly valuable regarding compliance with healthcare laws and regulations. By leveraging their knowledge and experience, you can avoid common legal and financial mistakes that could jeopardize the sale's success. This includes mistakes that might impact associate agreements.

The Role of a Sell-Side Advisor in DSO Transactions

A sell-side advisor plays a critical role in managing the sale of a dental practice to a DSO. They prepare and present the practice in the best light to attract the highest offers. Their in-depth understanding of the market helps set a competitive and realistic price, enhancing the practice's appeal to potential buyers. Additionally, they coordinate all aspects of the sale process, from initial valuation to final negotiations, ensuring a smooth transaction.

Avoiding Common Mistakes When Selling to a DSO

When selling your dental practice to a DSO, it’s crucial to be aware of common pitfalls. Inadequate preparation, poor understanding of the market, and hurried decision-making can all lead to unfavorable outcomes. These mistakes can not only diminish the sale value but also affect the long-term success of the practice post-sale.

Steering Clear of Gimmicks and Misleading Offers

Be vigilant about offers that may contain hidden terms or misleading promises. Some DSOs might present attractive upfront numbers contingent on unrealistic future performance metrics, such as the operatory count. It’s important to critically evaluate each offer and consult with your advisors to ensure that what is presented is what you will receive.

Selling to the Wrong DSO

Choosing the wrong DSO can lead to a clash of cultures, disrupted practice operations, and unhappy staff, ultimately impacting patient care. Selecting a DSO that aligns with your practice's values and has a proven track record of successful integrations is vital. Understanding their business model and long-term plans for your practice is key to a successful partnership.

Not Asking Correct Questions

Failing to ask the right questions during negotiations can leave you in the dark about important aspects of the sale, such as future roles, changes in operational control, and financial adjustments. Questions should be thorough and cover all facets of the agreement to ensure no surprises after closing the deal.

Not Having Strong Legal Representation

Without strong legal representation, you may be vulnerable to terms not in your best interest. A skilled dental attorney will scrutinize every detail of the agreement, negotiate better terms, and protect you from potential legal issues in the future. They ensure your rights are safeguarded and the contract reflects your best interests.

What Does Selling to a DSO Mean?

Selling to a DSO means more than just transferring ownership; it involves completely integrating your practice into a larger organization with its operational methods and culture. This transition can significantly change how services are delivered, how staff are managed, and how the practice is marketed. These changes require careful management to maintain continuity and protect patient relationships. This will boost the rate of patient retention.

The sale also typically involves restructuring many practice operations, which can include new technology systems, new management practices, and sometimes even a new physical layout. While these changes can bring about growth and efficiency, they can also be disruptive in the short term. Effective communication with staff and patients about what to expect can help ease the transition and set the stage for future success.

Planning Your Exit: Steps to Sell to a DSO

Planning your exit strategy early is crucial when considering selling your dental practice to a DSO. It allows for a thorough market and potential buyers assessment, ensuring you make informed decisions. Proper planning enhances your negotiating power and can significantly affect the sale outcome.

Start Assessing the Market Early

Begin by analyzing current market conditions for dental practices similar to yours. Understand trends, such as the increasing involvement of DSOs in the market, which can influence the valuation and demand for your practice. This early assessment helps you pinpoint the ideal time to sell based on economic factors and DSO expansion activities. Being proactive also allows you to adjust your practice operations to make it more attractive to potential buyers.

Research Potential DSOs Early

Investigate various DSOs to identify those whose strategic goals align with your practice’s values and operational style. Consider the size of the DSO, its geographic presence, and reputation within the industry. Look into their typical deal structures and how they integrate new practices into their network. Understanding these factors will help you target the right DSOs and avoid lengthy negotiations with unsuitable candidates.

Collect Offers From Multiple DSOs

Gather multiple offers to ensure you have options to consider, which can lead to a better final deal. Each offer may include different terms, from purchase prices to commitments regarding your post-sale involvement. Comparing these offers side by side gives you a clear picture of what the market values your practice at and where there might be room for negotiation. This step is vital in determining which DSO understands the true value of your practice and is willing to reflect that in their offer.

Negotiate and Leverage Offers

Use the variety of offers to your advantage by leveraging them against each other to improve terms. Discuss aspects like upfront payment, earn-out periods, and retention of certain rights post-sale. Effective negotiation can significantly enhance the financial and professional terms of the sale. It's also important to maintain a clear line of communication with potential buyers to address any concerns and finalize the best possible deal.

Review and Sign a Contract

Review the DSO sale contract with your dental lawyer to ensure all agreed terms are documented and beneficial. Pay attention to clauses related to financial arrangements, staff retention, and any obligations you might have post-sale. Make sure that all legalities are covered to prevent future disputes. Signing the contract is the final step in your practice sale, sealing the terms of the transition and starting a new chapter in your professional life.

How a Strong Dental Lawyer Can Help You Make the Right Decision

• Expert Guidance: A dental lawyer specializes in the nuances of dental practice sales and offers tailored advice that can protect your interests.
• Contract Negotiation: They can negotiate on your behalf to secure favorable terms that respect your plans and current practice valuation.
• Legal Protection: They ensure that all legalities are addressed, preventing potential legal issues post-sale.
• Risk Management: A dental lawyer identifies risks in offers and advises on how to mitigate them.
• Comprehensive Support: From initial valuation to final paperwork, a dental lawyer supports every phase of the sale, ensuring compliance and satisfaction.

Contact Dental & Medical Counsel for Help Selling Your Dental Practice

At Dental & Medical Counsel, we specialize in guiding dentists through the complexities of selling their practices to DSOs. We understand the importance of securing a deal that values your hard work and preserves your practice's legacy. If you're considering selling your dental practice, contact us today to ensure you make the best decision for your future.

Frequently Asked Questions

Q: What does it mean to sell your dental practice to a DSO?
A: Selling your dental practice to a Dental Support Organization (DSO) involves transferring management and operational responsibilities to an organization that supports dental practices. This shift can increase efficiency and profitability by allowing you to focus more on patient care rather than administrative duties.

Q: What is a DSO?
A: A DSO, or Dental Support Organization, provides management and operational support services to dental practices. These organizations handle areas like marketing, finance, human resources, and purchasing, which helps dentists focus more on clinical work.

Q: What are the benefits of selling to a DSO?
A: Benefits include improved operational efficiency, enhanced financial growth, access to advanced technology, professional management support, and targeted marketing for patient acquisition.

Q: How should I evaluate unsolicited offers from DSOs?
A: It’s essential not to jump at the first offer. To ensure you get the best deal, create a competitive environment by reaching out to multiple DSOs. Highlighting your practice's unique aspects and engaging a professional broker can lead to better offers and terms.

Q: How can I create competitive bidding for my dental practice?
A: To attract multiple DSOs, emphasize unique practice features, work with a broker, prepare detailed financial reports, and highlight patient loyalty and growth potential. Engaging with several DSOs at once can foster competition.

Q: How do I select the right DSO partner?
A: Choose a DSO whose values align with your practice’s goals and ethos. Evaluate each DSO’s track record, their integration approach, and their cultural compatibility with your practice to ensure a smooth transition.

Q: What financial aspects should I understand when selling to a DSO?
A: Understanding EBITDA (Earnings Before Interest, Taxes, Depreciation, and Amortization) is essential, as it reflects your practice's profitability. Additionally, the EV/EBITDA ratio is a valuable valuation tool for comparing offers.

Q: Why is professional representation important during a DSO sale?
A: Experienced advisors and dental attorneys provide vital support, navigating the legal, financial, and strategic aspects of the transaction. They ensure your interests are protected and can negotiate favorable terms.

Q: What mistakes should I avoid when selling to a DSO?
A: Common mistakes include inadequate preparation, accepting misleading offers, selecting an incompatible DSO, failing to ask critical questions, and not having strong legal representation. Avoiding these pitfalls can lead to a more successful sale.

Q: What is the role of a sell-side advisor in DSO transactions?
A: A sell-side advisor helps present your practice attractively to potential buyers, sets a competitive price, and manages the transaction process, from valuation to final negotiations, to ensure a favorable outcome.

Q: How can a dental lawyer assist me in selling to a DSO?
A: A dental lawyer provides expert guidance on contract negotiation, legal protection, and risk management. They support every phase of the sale to ensure compliance, mitigate risks, and secure terms that align with your goals.

About the Author

At Dental & Medical Counsel, we've been instrumental in realizing the practice goals of countless dentists. Whether you're looking to purchase, launch, or sell a dental practice, our expertise is your guide. Beyond the initial stages, we're committed to ensuring your dental practice remains legally compliant.

We provide comprehensive support, including employment law protections, dental contract reviews, and assistance with dental employment agreements. Additionally, we specialize in incorporating dental practices and securing trademarks. And for long-term planning, our services extend to helping dentists with succession and estate planning. Trust us to be your partner in every step of your dental practice journey.

About Ali Oromchian, Esq.

Your Dental Lawyer

Ali Oromchian, JD, LL.M. is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters

Ali Oromchian, JD, LL.M., is a leading legal authority in dental law and the founding attorney of Dental & Medical Counsel, PC, with over two decades of experience. His deep connection to dentistry comes from his wife's nearly two-decade-long career as a pediatric dentist. 

This personal insight fuels his dedication to empowering dentists to navigate their legal challenges and achieve their practice goals. In doing so, Ali has helped thousands of doctors open their practices while maintaining legal compliance. 

Ali is frequently quoted and contributes articles to dental publications, including the California Dental Society, Progressive Dentist, Progressive Orthodontists, Dentistry Today, Dentaltown, and The New Dentist magazines, further showcasing his commitment to the dental community.