A DSO Horror Story

[MUSIC PLAYING] Set down your sleepy water in your Mr. Wessel. Take off that raincoat and grab a cold beer. It's time to have a real talk about pediatric dentistry. You're listening to "Brews in Tiny Teeth," the unfiltered pediatric dentistry podcast. What's up, "Brews in Tiny Teeth" fans? It's your boy, Casey Getz. Got a great episode today. You guys are going to enjoy this one. Big focus discussion topic is DSO Horror Stories. Topic, that's hard to get people to talk about, but I found a guest who did a great job. We kind of dove in to some of the pros and cons of working in a DSO. But I just had one quick housekeeping announcement that I wanted to come at you guys with. So many of you know, myself and Dr. Corey Hasting have a startup course that we created. It's an online virtual course. It's called "Little Smiles Practice Mastery." Tons of you guys have taken it. And plenty of you have probably not, but if you are interested in learning more about the business side of pediatric dentistry, that's what that course is all about. We recorded it a few years ago, and we're always adding content to it to try to keep it fresh and relevant. And so we had a great partner with that course come up and we recorded a webinar. So we had Joe Lucido from Clear to Launch Healthcare Marketing. So we wanted to do a webinar that was all about, you know, how to put your practice ahead from a growth standpoint in learning how to use social media. So it's all about social media, Instagram, TikTok, how to make content, how to post content, what gets likes, what gets follows, how often to post the type of content that does really well. You know, there's a changing field. There's always a lot there. And so Clear to Launch, they work with Dennis, they work with physicians, they work with kind of anybody in healthcare, but Dr. Corey, who's a pediatric dentist in my partner in the course, uses their firm, and he's used them to really help grow as social media reach and acquire new patients. And that's something we talk about a lot in that webinar is, you know, not just getting likes and shares and clicks, but actually getting new leads that convert to new patient phone calls and get butts in the seats. And so that webinar is great. We recorded that one. That one's gonna drop on September 4th. If that's a webinar, you guys wanna check out. Feel free to check out Little Smile's Practice Mastery. It's a membership-based course, but it's very affordable. You can do it month by month. So if you're in the midst of owning a practice or have a startup and you want access to some of the materials, feel free to check us out there. Those webinars are only available if you're a student of the course. You can either buy it on a monthly basis or sign up annually. So just wanted to revisit that. We try to add a lot of good content to that course. But it's a great resource for docs like myself that are passionate about business ownership, wanting to start a practice, wanting to be a practice owner. So encourage you guys to check them out. Or if you have a young practice and you want some help growing your social media presence, check out Joe and his firm at Clear to Launch. That's cleartolaunch.com, by the way. Great guys there. So check those guys out. If you have any questions, send me a message, but otherwise enjoy today's podcast, guys. Thank you. But I love how you'll even rock like your classic signature, like fun t-shirt on a residency day. Do you have like throwback Nickelodeon on this one? Yeah, this is all the Nickelodeon cartoons that like we grew up with. Do the 90s, Red and Stimpy. We got monsters, real monsters. Yeah, I mean, it's a solid one. It's funny 'cause I get more parents that are like, I trust you now, just because I have this. Yeah. That's my favorite when kids are, you know, they got to pick a movie out to watch on the TV on the ceiling and you're just watching Blue Ian Frozen on repeat, you know, sometimes a teenage you'll be like, I literally don't care. I'll be like, we're gonna watch Emper's New Groove or Sandlot or Mighty Ducks. Like those are my three go too. It's great. Just started watching Mighty Ducks with my girls. That's fantastic. I know, they're like, yeah, this is great. Speaking of which, you have three, 'cause I pulled you up 'cause I couldn't remember what your practice pitch was, but I didn't know you had three girls. That's pretty cool. Yeah, yeah, it's fun. Yeah, we've got a third girl comment. So I'm being the same boat, but on Halloween. So I'm gonna have a three-year-old, one-year-old and a newborn-all girls, which is probably pretty somewhat similar stretch. Are you kind of in the range? It looks like 12-9 and 6. Yeah, it's pretty good. Yeah. There's a bill for a girl, dad. I feel like you, I don't know. I won't say thrive, but I like it. Yeah, I think you do well with it. It looks like. I'm not a super manly man. And so I think for me, it was kind of like a sigh. And also like, I think you're dealing with like crazy kids all day. And so I'm like so stressed. So when I finally come home, I feel like my girls are pretty calm. They're pretty peaceful. They're just not broken stuff. So I can kind of come home and they're like, Dad, and you just get this love and affection. We're like, okay, this is pretty great. So I talk about that. Girl, that's what's up. My wife, 'cause I was a little disappointed, I didn't get a boy on this third one, but she's like, think about what it's gonna be like when we're old. You'll have a fleet of gals to take care of you versus if you have a bunch of boys and you're 80 and on your deathbed and sick and chronic illness, like those kids, they have their own career, they're not gonna check in on you, but you're gonna be babyed and pampered, you know? - Oh yeah. - Yeah, so we're just gonna cash in on the benefits late in life, I think. - Oh, heck yeah, absolutely. - Well, dude, I know thanks for making the podcast happen here, Mark. You know, you and I, some backstory for listeners, like we had kind of touch base about making this happen a little while ago. And so I asked you, I was like, okay, let's come up with some good topics, some hot button topics to talk about and you send me a great list of things that we can hash over the big one being like some DSO horror stories, which I know, I've talked about before, I've tried to do an episode before on people sharing kind of their rough experiences with, you know, working for a DSO or selling to a DSO, but it's pretty hard 'cause people are scared about, you know, lawsuits and getting in trouble, you know? So it's hard to talk about it. So, so I just kind of dive into that amongst a few other topics here, but maybe just to give listeners some background like I like to do, can you tell everybody listening a little bit more about your practice, your adjuncting today, but just kind of give us some background details on what you're up to these days? - Yeah, so I did my residency, I'll start there, the before like there's a whole life there, but did my residency at the Children's Hospital of Colorado right out of residency, I actually worked for a DSO in that Denver area for about a year right before COVID hit. I was like, man, like this city life is kind of crazy, what kind of opportunities, like it's so expensive here, and opportunity popped up here in Oklahoma. And so I was like, you know what, this seems like an awesome thing, we went out and visited it, we had some friends that lived out here, but no family connections, and we just felt really good, so we made the move, moved the family, and that's how we wound up in Oklahoma. I started working for a DSO out here, it was a smaller DSO, I was the second pediatric dentist, and it was like, hey, like you can establish things that you want, you can get quality of care, like all these things, and it started out, you know, honestly pretty good, kinda stayed out of my hair and just kinda let me do, let me do my thing, and it was really exciting to see things grow that quickly turned into like, well, you're making a lot of money off of me, and now we're running into issues, and there's more things happening. I think at some point you eventually realize what gaslighting means, and you eventually realize like, where words don't matter as much as actions, and there was kind of a strange relationship for a while. I think about two years in there, like, hey, we're gonna, I told them I said, hey, here's my ultimatum, either I'm gonna buy this office that's down the road with or without you, so this is what it is, and they quickly said, oh, you know, we'll buy it, we'll do all these things and made a lot of promises, and I said, well, my whole thing is, I need to remodel this office day one, and they're like, yeah, yeah, no, we get it, we're gonna do that, we'll fix a couple things, and then at that point, like, the day we close, like, hey, we need you to get in there and start working, we don't have money to remodel and do these things, so like, well, that was the contingency of this, so it was just like day one of closing, I was like, okay, this isn't gonna work out. It quickly, quickly turned fast, and I can get into that story a little bit more down the road, but I eventually left that DSO, and I gotta go work with a friend up in Bartlesville, who's also been on your show here, John Lindblum, and I'll work with him, he is the man, and I think I gotta see what a selfless person looks like, and somebody who's doing things for the right reason and cares about kids, and it was really eye-opening to me that you can make such an impact in your community, just being a pediatric dentist, you could make impacts everywhere, and I said, you know, I wanna be like John, I wanna do that, and so slowly worked on trying to build an office right by my house, while I was in the process of building another dentist approach to me and said, hey, I'm gonna close my doors to this pediatric dental office, I'm not selling to a DSO, but if you wanna buy it, I'll sell it to you. I said, well, I'm building an office, I can't do two offices, and he's like, well, I'll sell it to you for less than the cost of the equipment. I was like, okay, (laughs) and so, August, 2024, I bought his office and started working two days a week there, and then January, 2025, I started going full-time at this small little office, and then in July 2025, I opened my second location, which was my ground up build. So, within a year, opened up basically two offices. - Wow. - So, you gotta get a startup and an acquisition almost simultaneously, that's wild. - At the same exact time, yeah, I know it was so dumb, I'm so dumb. - Yeah, you know, the first thing that comes mind is, you know, was there, were there lending issues trying, I guess if you got the acquisition for- good enough price maybe it wasn't an issue trying to get lending on both practices. So I already had the loan going for my other practice and I just didn't tell them about the practice that I acquired and funny enough the lady who does the lending. It was through Bank of America and she lives in my neighborhood and she's like, "Dude, I just saw that you have an office in Broken Arrow. What did you do?" I'm like, "You don't need to know about it." No, please don't tell me, but congratulations. It was probably a little bit behind the scenes on some of that stuff. But it's worked out really well and it's been really interesting to compare the difference between an acquisition and a fresh startup. There's pros and cons to both and I think it takes a totally different skill set between the two but I think both can be super beneficial. Do you and John parted ways with John's office? Are you still associating or working with him at all or how did that go? No, it went good. We live about an hour away from each other so I was commuting 60 miles each way and it was so great and I still text John and I love talking to him and I miss him. He's still one of my role models and idols and sometimes I'll head him up for questions and we'll try to chat but I think a part of ways good, I mean hopefully I didn't leave a trail of tears or anything but it was really good to have a role model and I think going into it I knew that I would be parting ways. It wasn't a permanent thing and he knew that going into it and he's just one of those guys that said, "Well, I've already done this. Let me help you build an office. Let me help you do this." So he was very transparent and he was so crucial to me being able to do this and I think that mentality, I want to replicate that so other people that want to start an office great. Like, let me help you. There's no competition. There's so many kids. We just need good providers. Yeah. You know, that episode we recorded several years, three years ago but he was still one of my favorite guests just because I didn't know what to expect. You know, a little comment on Ipedo and stuff but he's just such a cool, unique personality where I feel like he, you know, he's kind of just, I don't know, you tell me if you disagree but just doesn't seem like he cares what people thinks. He does his own thing, he's got tattoos and, you know, cool glasses. He's got his own kind of really unique style and he does these really awesome paintings. You know, he's talking about his painting studio that he's really skilled at painting. But I remember he told his story. He was the one that got me into using like, "Beautiful Blue," which we've talked about like, "Flowable for Class 2." He kind of-- So amazing. Which was game-changing and then he, I know, he also had kind of an interesting practice journey to where he had a busy practice and then, you know, because one of the topics we're talking about is DSO's and I know at the time it was a good relationship for him. He had told me he sold his practice to a DSO, you know, and who knows. He obviously is still practicing and working there so it'd be interesting to do around two and see, you know, how that relationship has kind of evolved. But that was-- I remember in our conversation we talked about that and it was productive. Yeah. I think you'd have to ask him on that, man, like I said, it's one of those things that we had talked about that. It's like, man, I wish I would have met you like, we would have started this relationship just a few years before because I think both of us would have agreed that, like, partnering or doing something together and creating perpetuity of practice would have been better overall. For sure. Yeah. Yeah. What-- tell me about-- so I didn't realize you worked for a DSO in Denver as well. Because, you know, when we were talking about some of the shady things and sketchy things going on, that seems like it was more with the Oklahoma-based DSO. Did you have similar instances with your-- when you worked for your DSO or your big practice in Colorado or what were the similarities and differences between your experiences with the two? No, it was pretty different with the group that I was with in Denver. I think they do a really good job. They have since actually-- the pediatric portion has actually separated out from the actual DSO. And they were, like I said, great providers. I think I was just-- you know, that first year out of residency, you think you're hot snot, and you think you're awesome, and then, like, day one, you get humbled. Where you're like, oh man, my class dude looks like trash. I think I was still focusing on that. I was still on the selfish part of things where I was trying to figure life out a little bit. But like I said, I think they're a great group of guys. And I think the DSO was structured a lot differently. My issues with things in Oklahoma were very different. And I got to see a lot more, maybe intimately, how the money-making schemes and how things just aren't in favor of dentists. Even if you're a dentist trying to do a good job, like, my question to you was like, what is the DSO going to do to actually help you? And the answer is nothing. Yeah, that's-- there's definitely a caveat there, because people think, you know, obviously haven't sold to a DSO, but you think you partner with the DSO, and they're going to take over all the stressors. But I always think, like, they're still just an invisible entity in outer space out there. And like, when an employee has an issue, and they come and shut the door, like, you're still the one that is going to have to be dealing with the hardest part of the job. Yeah. Yeah. It's still your license. They have no liability on the things that they're doing. I mean, we can be time and time again that they can do a lot of things within the legal realm, and they're not be held to the same practice standards that a dentist is. So if there's something clinically that goes wrong, it's totally going to fall on you. Business ethics are very, I would say, ethically gray, regardless. And there's a lot they can get away with without legal ramifications. And so the question I would tell every dentist, I'm not saying all DSOs are bad or that you shouldn't ever work for one, but it's just like, let's put numbers to it and say, like, well, how much is the practice paying the DSO and what of those services could you not get with specialized companies that wouldn't cost less? I just think about that the platform expense could be anywhere from 10 to 12 percent of your monthly production at 10 to 12 percent. Like, I mean, I was listening to your last podcast where you kind of talked about your percentages and numbers. I'm like, 10 to 12 percent of your entire collection, like, you could do a law and take a couple of vacations and still be in the positive rather than paying a DSO. For sure. That's just something to think about. So I want to dive into the weeds a little bit on this one, and we can start with the disclaimer. Obviously, you don't need to share specifics to the extent that not get you in trouble. But I think it might be important for listeners to kind of understand some of these nuances, to kind of know what to avoid when new jobs, new associates are trying to find a group to jump in with. Maybe look for red flags and know which ones are good to jump in with. So could you maybe tell me a little bit more in your specific instance with your associate chip in Oklahoma? That was the makeup of this DSO. You said it was smaller. Was it was the ownership there from like dentist? Were dentist owners in this practice? Was it strictly private equity? What was the backstory like prior to you getting on? I'm just trying to set the scene to kind of see what this was like. So when I had joined, some of the specific questions I asked were, hey, does private equity own the office that I'm going into? What's the ownership potential? What's going on? Well, hey, no, it's just dentists, you know, the company and dentists own this solely. Yeah, there's totally ownership potential here. And that's what I was told. I knew that they had been talking to private equity, but what I was told was different. And I would say that was on me because I didn't get it in writing. Like honestly, anything that's verbally said or if a big red flag is saying, oh, let me call you. Anytime somebody says that and they won't put it in an email or they won't put it on a contract, there's a, there's a business tactic that a lot of companies and like business schools will teach where they teach confusion or ignorance or like, oh, I didn't understand. They teach that as a tactic to claim innocence when something is maybe more intentionally done. And that seems almost like a conspiracy, but it is a tactic. It is something that's taught. If they're not willing to put it in writing or put it into a contract, you need to ask yourself why and like what issues do you have? And then hold your ground, say your ground. So I was told that there was no private equity involved. I came and I found out within a month actually, yes, private equity had or he bought them, they'd come in and done a purchase from all the existing offices. And that was, that was the kind of the first red flag. And at that point, there was still an owner doctor and like I said, he's a nice guy. I have nothing against him who is extremely helpful in helping me and he quickly actually moved out of state. They were expanding into Missouri actually towards you. And so he moved over to Joplin. And so he had all these pediatric offices in Oklahoma, but he was a state away. And it left me as the pediatric dentist that was there basically making decisions. And I thought it was like, well, this is my proving ground. That's what they want to see. And I was really excited as a new dentist to show, I want to show them what it's worth. But I think I backed myself into a corner because I was doing all this stuff essentially for free. And so when I said, hey, at what point do I get ownership? Why are you going to buy the cow that gives it to milk out for free? And I think that's something that you should establish and get in writing from day one, explicitly should be in a contract. And that was another mistake that I would say that I made. And the conversation that I had about a year in, I met down with the CEO and founder. And I said, hey, there's a big issue. Like you're a general dentist company and you want to dive into specialty. But there's no incentive for specialists to come in. If you're going to sell it to private, actually, like if you want to create perpetuity, we need to have a structure. that incentivizes dentists coming in so that new dentist can have ownership in the office up there at. And this whole model, I kind of laid out a model of saying, "Hey, there's equity percentages and ways that you can buy in that you can keep this going." And they said, "Oh, it's a great idea, but we're not going to do it with you." And they said, "But we'll give you two offices in the next 12 months." It was a handshake deal and said, "Well, like, yeah, that sounds great. If you can help me get two offices, like, I know where I want them. I know what to do." And that was kind of the dangling carrot. I didn't get it in writing. I didn't get it in a contract. And yet again, words failed me. Fast forward, you know, I got that one office. They tried to then make a general office saying it was a pediatric office and that didn't work. And then at that point they were building other pediatric offices. And no, these aren't yours. We're keeping all the equity in the, you know, so it just became this one thing where it was kind of a bait and switch every single time. The precipitating event that led to my leave was it had been 11 months and we had almost, let's see here, we had doubled the size of this practice that I had bought in 10 months and our overhead was zero, not zero, but it was really low. And I said, "I haven't gotten any profits." Like, what is going on with the financials? So I sat down and I said, "Hey, there's about three or four hundred thousand dollars of claims that have not been collected." And like, you guys are in charge of sending these claims out and it doesn't even look like they've been sent. I'm not getting paid for those and I'm not getting profits. There's something like, "What am I paying for with these platform expenses?" I said, "Well, you actually owe us money for capital expenses." And I said, "Well, that's not true because I actually did most of the renovations myself out of my own pocket because I wanted the office to look nicer and you guys weren't going to do that." And I said, "Well, the CEO looks at me and he's like, "You just don't know how to spend money. You don't know how much things cost your terrible businessman. I trust my guys and their financials." Like, point blank in this meeting with everybody and I said, "Well, pull up the financials. Let's look at it." Oh, we can't do that. Excuse me, you can't pull up the financials. So it took them a week to get the financials. I came into another meeting and I said, "There was just an innocent accounting error. We were off by about $400,000." So actually, we actually, you know, here's a check. That should account for what we owe you as your ownership portion. I was like, "So what was the accounting error?" Well, you know, basically the debt that we acquired from buying the office, we put it as a ledger to you so that you owed us all that money. So I'm like, "So you mean that I bought the entire practice and that you weren't going to wait for me to buy the entire practice and take that?" Like, "No, that's not what happened." And so that happened. And so the ultimatum, and I'm going into prime more detail than you want, was like, "Hey, something's got to happen. Either I'm not going to pay my platform expense because you're not doing the services or you can pay me on the claims that you haven't submitted. Those are the two options to make amends." And they said, "We're not willing to do that. We're not going to do that. I trust my guys over you." I said, "Okay, well, we need to part ways." And that's what started the leave of this DSO. And from there, it was just kind of a big mess, but I have emails of how they tried to on the dissolution agreement the night before I was supposed to sign. They added multiple offices that I have never set foot in. They put offices on a non-compete that weren't even built yet. They said, "Any office that a pediatric patient had had sedation in was now a pediatric office." And that agreed to the non-compete. Just some really shady things. And then, when I would walk over towards where their offices were, I'd get a text from the CEO at the time, and I have saved the text and the email saying, "We just think it's done that you're walking over here. We all think you're so stupid." Just like little childish things. And the thing is, people are willing to tell you nice things when you can help them. But who are the people when you can't offer them? When you can't help them or you don't have something to give to them, they can't make money off of you. How do they act at that point? And I think that's a real interesting issue is, do you want to work with people that want to do good things for the right reason? Or do you want to work with people that are just trying to make money at the end of the day? And I honestly could care less about the money. I got to pay my bills and take care of my family, but I think as pediatric dentists, we got into this career not to just like make bank. There's cheaper, there's easier and better ways to make money than pediatric dentistry. But I think we would all do better to say, "Hey, what's our end goal? If our end goal is to make the world better to help people, we'll probably get along. If my end goal is to make money for shareholders and stockholders, we're probably going to disagree at some point. We probably shouldn't do business together." And I think that's probably the starting point. Well, thanks for, I guess, to start. That was very open and transparent, which we've talked about and people don't like to do. So love, you did a great job of walking us through that and being open about that. So that's great. It also just what strikes me is how convoluted and complicated all these deals seem. You know, like, versus, you know, now you're your transition and your startup, it's cut and dry like you're the owner, you do what you want to do, all the profits yours, all the debt is yours. But man, that's always, even if you have a good DSO, that treats you well and you get everything in writing, it still just feels so complex having, you know, a non-owner, like yourself, you know, kind of dangle some sort of little carrot. Like, we're going to have you go start, you hear that, like, "Oh, I work for this DSO and they're going to have me go start this practice." But it's like, why not just go, like you said, you know, maybe they have some resources, but you could probably do it yourself and then you keep all the profit versus you take on all the stress, make all the phone calls, do all the meetings, and at the end of the day, you don't really get the, you know, the cream on top, which you should get if you were an owner. Yeah, yeah. You know, and I think a lot of people are afraid of the complexity of business, which I get, I think it is, but to anybody that's like looking to start a practice, or they're scared, they want to do a DSO, it's like, honestly, just like, MBAs don't know any more than you about business. I promise you that, and whatever they do know, I also promise you that cloud and chat GPT could probably tell you more, and they could do the same equations and the same rubrics, and I think we're so scared we've become such perfectionists that we don't want to make mistakes. To that, I would say, like, you're going to make mistakes. You're going to do things wrong. However, there's enough people around you that are cheering for you. Like, I have probably six or seven dentists that are all trying to start offices and do stuff, and they'll text me and call me, and I am more than happy to spend as much time saying, don't do this. This is the stupid thing I did. You know, and try to give them encouragement and lead them, but I mean, there's enough pediatric dentists that'll do that for you. It's like, go out and meet a couple, text them, reach out to them, get on a Facebook group. All of us are honestly rooting for you. Even if you're in the same town as me, I'm going to help you out. Like, I'm going to root for you. And so I'd say, like, don't be scared. Find a collaborative group that wants you to succeed because we want the world to be better. Don't just go into a DSO because you think it's simple or it's easy or they're going to take headache away from you because that's just not the case. There's plenty of other options. And even then, like, like I said before, there's no service that you can't find for cheaper outside of a DSO like marketing. You can find that for a lot cheaper claims processing, billing, all of those things that DSOs offer. Like, they're going to help you out. Even when it comes to hiring, I haven't met any offices where a DSO is able to hire for them quicker or better. That's always a sticking point. As I can pay my assistance, whatever I want. If there's a great assistant, I'm not going to have to submit it to the regional manager, which then goes back and forth. You know, it's like, hey, you need this, you're worth this. I need you right now. Let's do it. So I've been impressed that it's just a lot easier than I thought it would be outside of a DSO. You know, I think I just kind of reminded me, and I forgot about this, but I think you joined in our using Pito bill. This was like a great example of this. Like, you know, that you pay two and a half percent to have all your insurance collections and insurance work process for you. But, you know, like I said, if you're given 15 or 20 percent to a DSO, you've got a lot of wiggle room in that budget, and that two and a half percent can take like a crazy amount of work and stress and manpower out of the practice by outsourcing that. But that's like just one example. Besides marketing, your payroll, you know, your advertising, but your revenue cycle management, like all pretty easy things now to outsource where then, you know, to your point, I think even opening now, there's certainly a lot of hard things about it in today's day and age. Like, it's a lot more expensive, but there's a lot more resources available. There's, you know, AI is just going to tremendously continue to make things better. You know, like if I had chat GPT when I was opening, I'd be on that thing every day, like constantly, you know, so there's a lot of resources now that weren't around even a couple years ago, which kind of helps. Oh, yes. I think the other thing too is the direct accountability. Like when you're part of a DSO, they handle all those things. So none of the services are accountable. They're not accountable to you as a doctor. They're accountable to the executive team. So you don't even see the back end of it. So you don't know what's happening. You're left in the dark, which it seems like it would be a less stressful until you don't get paid or tell you there's big problems. And then you're having to like look for the needle in the haystack, you know, pito billing, like they're accountable directly to me, like they're dashboard, all the things that are happening. I know exactly what's going on marketing. I get a report that says, hey, here's how your SEO is doing. Here's how your website. Here's how many clicks you have. Here's how much money you're spending. Here's the cost per conversion. Like you're paying for those services and you're getting concise information. But not only that, if you want something, they're going to answer directly to you. not somebody's three layers up for sure that's a great point yeah you don't same with like the financials and accounting is another big one it's like that's a bad part of the DSO but if if you're working directly with an account or somebody kind of managing your taxes and looking at your books and stuff you know it's easy to just like you send me my I want a profit and loss report I want to know you can ask for whatever and they're gonna send it right to you and you it's not gonna get obscured or twisted or you know they're not gonna give you weird numbers like it just seems like trying to derive information out of DSO you never hear it going well yeah well to your to your point on the accounting whether they do cash versus a cruel accounting I'm kind of getting into the weeds here but you should get a PNL for your practice if you're part of the DSO anytime there's a cruel accounting look for like random line items because they'll do a cruel accounting based on next month's projections it's really easy to hide 20 30 40 grand a month based on some of that are cruel accounting and so it's it's not transparent it's really convoluted and that it's a risk directly to the dentist to be honest yeah so if you if somebody younger was was talking you mark and asked about you know I do want to work for a DSO because maybe I want to start a practice but I need to get my speed up I you know I need to just get busy and makes money like what are some tips you would have for like here's what I would look for if I was gonna do it again and try to find a DSO to make the best relationship with in a healthier scenario it seems like the big one you hit on is get things in writing that sounds good but any other any other ones like the ways to weed out the good ones versus finding the bad ones are tips if you're gonna do it again man that that's really tough because I think there's a lot of bait and switch the sounds really bad but anybody that relies and says like oh it's good Christian values and they rely on that like I'm not gonna trust somebody that tells me their Christian because like if you gotta use that as a telling point I would rather see your actions and see what's going on and just to throw that out there for anybody that's looking based on religion maybe just set that one aside because that's that's not a selling point to a practice I would say but I would say like is there an owner doctor that's present in the office are you working alongside another doctor or are you gonna be all on your own because I think those first years of having mentorship of a doctor that's alongside you is extremely crucial if they're just gonna throw you on to rule wherever you might gain some speed but you may not get the feedback that you need to become better and I think even having been out of practice for several years having that mentorship with with John Lindblum that those like 18 months were way more valuable than all the preceding years because I got instant feedback or I got to talk to somebody and I think it was also like a mental health reprieve having somebody to rely on so if you're gonna join a DSO are you gonna be on your own are you gonna have an owner doctor that has more experience because the other thing is I've seen lots of DSOs that will throw two brand new doctors into an office and it's challenged and then another thing I'll look for is do you report to a regional manager to the office manager does the office manager have more say or control in hiring and firing than you do if that's the case that's probably an issue and I would get those are things that would also get in writing if collections falls below 90% what happens are you responsible for that or somebody else is it are you paid on collections or production because if they don't collect that's not your fault so how's that how's that made up and there may not be great answers but those are questions and things that you should ask everybody assumes the most altruistic in result but when the rubber meets the road a lot of places aren't gonna back you up yeah yeah good good answers there sorry mark I was looking down at my phone because I know there's some other good topics that you brought up and if I'm not careful we'll spend the entire time like you know talking about why DSOs are challenging so I'll take as long as you want you can cut out all of my my junk you can throw whatever this is good I told you I wanted to do a podcast dedicated to this for a while so it fits in nicely but you had brought up a couple other things I at least wanted to touch on that I thought were good topics can you tell me about what the state of Medicaid is in the in Oklahoma because I I can't remember I want to say it's one of the more difficult states but I know there's a lot of like a large Native American population and stuff but what is that like is that challenging I think that's something you and I have talked about at some point but I wanted to revisit that to see what that's like in Oklahoma yeah we so I mean so perspective on this so currently I serve as the OAPD the Oklahoma Association of Pediatric Dentistry I serve as a president I've been involved as the vice president for the two preceding years and I serve on manage so we just got managed care about two and a half years ago and I serve on the board for one of those as well as the entire like group of all the managed care there's a there's a meeting with pediatric dentists I serve on that board and then I'm part of the Oklahoma Dental Association there's a task force for Medicaid and I serve on that so I'm in all these meetings we're trying to make some progress but the things that have happened we haven't had a fee increase in I think it's been 13 or 14 years and that only happened I believe because there was some litigation that they had to have it happen so this has been going on the fees are really poor there's a huge access to care at the at the children's hospital when it comes to getting OR time they're getting time cut and slashed there's just an overall access to care and it's kind of all coming to a head right now and then earlier I can't I couldn't tell you the exact time when the budgets came out for all of Oklahoma health plans they said hey we need 495 million dollars to fund dental and medical and they came back and said well we'll give you 250 million and so it sparked this huge like flurry where everybody's getting together they were thinking they were gonna have to cut benefits everywhere and we had tons of meetings where we went through the budgets and we were looking for hey where's their fraud abuse what codes are old and ultimately what it came down to is we were able to keep the fees where they're at we adjusted some fees but come February we don't know where things are gonna be at and I don't know what we're gonna get out of that but we're sitting here meeting and there's just some really illogical things that are happening and Medicaid like they had the fee for SDF set at 76 dollars but a single surface filling pays 67 dollars so what do you think people are doing you think they're gonna do a single surface filling are they gonna put SDF on it you're gonna throw SDF on everything for sure exactly now I mean ethics should say you shouldn't do that however there's people that are putting SDF on you know 20 teeth at a time and then punting or referring that out to a pediatric dentist and saying okay now you can fix those so there's there's rampant kind of abuse that happens and closing those loopholes has been a constant challenge but then also there's huge budgetary concerns because it's like we don't know what's going on so Oklahoma isn't a really rough place when it comes to the Medicaid and not only that we have a majority of kids that are on Medicaid and Oklahoma so that's the state of where we're at where it goes and how it progresses past this I'm not quite sure I know that Missouri's had a huge increase of fees recently and that's just been a huge boom to the children of Missouri some curious like what are some things you know what are some things that we can do in Oklahoma to to improve fees I don't I don't know yet dude I don't understand it either because it's weird that it just seems like there's some nuance of how the states work with the federal government to like advocate to get their half of the funding or something because it's it's it's weird that you guys already had such a low fee schedule and then they came back to you and said we're actually slashing the budget even more and it's like our already terrible fee schedule we have to shave off even more of that like nobody's gonna take Medicaid you know and Missouri is just the opposite like that just seems like I know there's a lot of behind the scenes work Missouri general association was really involved like all of a sudden I just got an email like oh we have all your fees are going up so it's like what what is it that I I just don't understand it just seems all very complex and there's a lot of people and committees and it just you wish you could wave an adric wand and make a better system and like at least come up with something where people can at least make a little bit of wiggle room profit on these procedures so you can at least cover it for kids and it'd be a reasonable common sense but like you said there is a lot of fraud there's a few bad apples that can kind of ruin it for everybody yeah it's it's tough you know and so last night there was a CE class that was taught at my office and there's two members of the board that were there and I said what's going on like let's chat about some of these things like and we chat it for quite a while but the end of the day we've got to get pediatric dentists involved in some of these they've got a volunteer for the committees why am I involved on like six different committees and I'm the only person and the only name and then you know it's we've got to have young dentists that are willing to sacrifice a little bit of the time if we shared that we could all be part of the conversation but historically what's happened in Oklahoma is we've had no specialist representation so we've had general dentists that have represented the policy for children's health for a long time and I'm not saying that these are malicious people however they may not be the best informed if you've ever watched a general dentist try to do a stainless steel crown you'll know that there's some gaps in knowledge that happened in dental school and it's probably our responsibility to make it better so it's amazing I've had these conversations with the board and some of the policies that bring forth for instance why is a strip crown paid at $207 but a zirconia crown for an anterior is paid out of $121 well typically general dentists aren't doing zirconia crowns but they are doing strip crowns because that's what they were taught so it's like what why do we have this world that's who helped us make the policy it's not that it was done [BLANK_AUDIO] It's just like that's what they're commonly using and they know that it's hard so they're going to pay that one more and that's what got advocated for. So as pediatric dentists for like this doesn't make any sense. But we need more pediatric dentists that are involved, not just in the pediatric dental society, but also involved with the state societies and getting involved with public policy and talking to the board and serving on these. Because if we're not chiming in, we're going to have people making decisions for us that have no clue what we do and it's going to affect our profession one, but it's also going to hurt kids because now we've got these weird crazy policies. Another weird thing, since I can, sorry, I'll interject here, going through the budget to the last three years in Oklahoma, they spent over $140 million on ortho and dentures through the Medicaid, to the dental Medicaid budget, $140 million. Meanwhile that is I think three or four times a budget for all the restorative codes for all of kids in Oklahoma. Wow. That's crazy. So money's there, but also that allocated correct. Exactly. Yeah. The number one complaint that comes through all of managed care and Medicaid is dentures. So there's got to be some decisions and some things made there, it's like do we want dentures more or do we want to take care of kids? Like we need to, like I hate that it has to come to a vote, but maybe we can like ease into it or make a little blended plan so that we're taking care of vulnerable populations without being too harsh, but that's kind of some of the challenges that we're having in Oklahoma. Yeah. You would think, I know I think Iowa is this way, and I've again, every state's different, but you know, if your state is being forced to kind of work with the limited budget and you didn't get, you know, the big increase from the federal side, I mean most people listening to this probably know, but Medicaid as part state funded and part matched by the federal government and some states get I think a lot more from the federal government than others. But it's like I think in Iowa, at least for a while it was adults with Medicaid would get extractions and like emergency treatment, treatment covered, which kind of makes sense, but you know, they're not getting endo and crowns and you know, a lot of extra pro stuff. But it's like at least cover your kids and I don't know pregnant women and emergency extractions, you know, maybe sealants like, you know, use some common sense with it, but it is a tough somewhat broken system in a lot of states. Yeah. And the challenge with covering more codes but paying a lower fee is it actually prices amount of actually receiving the services because either one providers drop all together or two, they have to make the decision that they can't provide that service because the fee is less than what it costs to do it. So we brought that and that like blew their mind because they had like a habit breaking appliance. I think it's like a D 80 20 and it was reimbursed at like 110 bucks. And it's like, well, that's not even the lab fee. But if you no longer included that code, offices, if they wanted to do this for kids could say, hey, my lab fee is 150 bucks, I'm going to charge you 200 bucks. Now suddenly there's a service they can provide for kids and they can choose the fee. I think we've put all the, I mean, by having the fee structure though, we've taken that opportunity or that option out of the hands of the dentist. And so it's almost better to not cover codes and let dentists set a fee schedule than it is to cover it low. Yeah. That's a good point actually. Yeah. That makes a lot of sense. Hard to explain that to some people that don't understand how that system works, but are you the, how many managed care organizations jumped in are involved? Did you say two or they're a whole bunch of them? We have. So we have two. We have DenneQuest and Liberty. And it's really interesting. The dental directors of both of those are, I absolutely love them. They're awesome, awesome individuals in the state of Oklahoma. Todd Ray was on the podcast from DenneQuest, you know, like, yeah. Yeah. Yeah, I love that. I love that. You know, and the two deaths that we have, they really are trying to do a good, they're trying to really help. And they're looking into it. It is really tough. The other confusing thing is that the state still hasn't stepped out. There are still people that are on the actual state, it's called sooner care. They have sooner care or you can have, you know, you can have Title 19 through Liberty Dental or Title 19 through DenneQuest. What happens is when they qualify, they're kicked down to sooner care within 30 days, they have to choose a plan. And so then what happens is you do this eligibility and they could go from one sooner care to DenneQuest, but then if they switch in 30 days, they could then go to Liberty all within a 30 day window. So you could see somebody for an exam on sooner care. The next day, they could be on a separate plan for their restorative appointment. And then two weeks later, they could be on the third plan for another restorative appointment. And it's, it's chaos, a nightmare. It kind of is. Yeah. Yeah. Okay. So there's something related to that. What in my notes? We talked about the Medicaid challenges. Oh, this, protecting our specialty you talked about with like reimbursement scale, sedation, you know, you said access to care is an issue in, in Oklahoma and every time I, I have an episode where I talk to somebody like yourself where that's, you know, I have to stop and reflect like how fortunate I am in Missouri, where if I have a kid that needs sedation, like having in office sedation and they take Medicaid, like having anesthesia coming, such a blessing and I take it for granted, but I listen to people like yourself where it's a challenge in those states, like thank God I don't have to, you know, you just, you think God I don't have to find a way to treat this four-year-old with 14 cavities who's uncooperative, like I don't have to find a way to do that in office, like I can just write them up and take them, but maybe you reflect on that, like how much of a challenge has that been like in Oklahoma, like what's that look like? Yeah. And so we do also have like in office, we actually have a lot of CRNA groups that come in office, which is great. We have been, they've been working on revising our sedation guidelines for I think like three years now and haven't, hopefully is coming across soon, but we have, for instance, we have a surgery center in Tulsa where I'm at, that they have all MD anesthesiologists that's a privately owned, like surgery center, I say privately on its own by a couple groups and then I think one of the big hospitals has an ownership portion of it. They have done, quote, pediatric sedation there for well over 10 years and they've never had a pediatric dentist that has done pediatric sedation until I, at one point in time, was taking some, I worked for a group and took over some, some cases for them and went to the surgery center and I went in there and I was like, oh, this is like, oh, you know, we've had pediatric dentists all the time, like no, you've had general dentists that have done pediatric dentistry, you know, and it's, I always correct people, not because I want to be a butthole, but like, I feel like it's important to correct people because if we don't, like, it just keeps getting propagated. So the first day I'm working on a kid and the MD anesthesiologist, he's, he's intubating him and say, hey, like, do you always use an uncuffed tube? He's like, oh, yeah, I always use an uncuffed tube, like, okay, well, he's like, where does that matter? Because I'm going to cut dry, like, I'm, I'm not going to cut wet on a, on a cuff tube or on an uncuffed tube because we're going to get water back there. It's going to slide back and he stops and he's like, nobody's ever asked me that and I always get bronchospasms when I'm doing dental. I'm like, well, not a single dentist he've worked with has ever been in an OR setting, not a single one of them has been trained. So the access to care, we have hospitals, we have surgery centers that there's no pediatric dentists. We don't have any privileges there and yet general dentists are getting this privilege and it's creating a safety risk where we're now, we're also seeing CRNAs that are coming out. They're sedating kids in rural areas where there's no hospital close that have never sedated kids before. And then you're having general dentists that have come out of dental school and maybe that on a weekend CE, so you have a new CRNA and a new general dentist and a rural part of Oklahoma and they're sitting kids and seeing those two years old and not patient setting. And to me, that's just, that's the recipe for disaster and there have been some, some issues and for me, we need to protect our profession. And by that, I mean, we need to protect kids. We don't need negative outcomes from kids and I think we need to set some standards and to make sure that we can keep kids safe, that's really what it is. But part of that is like, hey, we as pediatric dentists, we're pediatric dentists. We have extra training. Like we have a board certification, that should mean something and until we start making those distinctions and saying, hey, like maybe we should go to the state and lobby and say, you can't name yourself kids dental if you're all general dentists. I know that seems kind of harsh, but like we've got to make a stand otherwise we're going to find ourselves in 10 years, the general public already doesn't know the difference most at the time. We haven't done a good job of protecting that and now it's gotten so diluted that the state when it comes to Medicaid, they're not paying us a different piece schedule. Insurance is for the most part not paying us a different piece schedule. And we've created our own problem by not standing up for ourselves. Yeah, it's tough because it's like what are the actionable items you can do to fix that because I totally agree with everything you're saying. So then my thought goes like, okay, yeah, lobbying or having rules against like what you label yourself as so instead of dentistry for children or versus pediatric dentist. But I sometimes when I think about this, I go back to like I just have to put my money where my mouth is and like offer skills in a level of service that like your general dentist that didn't have training like, you know, can that they can do, you know, like be really good with the kids, you know, offer things like zirconia crowns and space maintainers. Not say a general dentist can't do those things, but I don't know, I just it's a tough problem, but it's also kind of a hard one to come up with a solution to a little bit to some degree. Yeah. Yeah. And I think it's gotten propagated so much that really, like I said, when the state officials and people don't know the difference between a pediatric dentist and a general dentist, and when realistically there's two years of training, it's turned into a point where now it's a safety concern. And it's hard to backtrack now. Once you've lost that right, how do you inch that back? How do you explain to them that, hey, when I practice in Colorado, you had to have a board certification of some specialty in order to get hospital time? Yeah. There's a group that does, like, a general dentist. and rural dentistry group in a rural area, quite a ways away from me like out in rural Missouri. But you see a lot of those in Missouri as well. I'm sure Oklahoma is the same way, but General Dentist Office in one of the general dentists like seeing kids and they bring in a C-R-N-A or I think maybe they go to a surgery center. But it's just like that seems to be where that, you shouldn't be, I don't know, I don't know if I actually agree or think that way. True or false, should General Dentist be able to do sedation and put kids to sleep. You'd have to have a lot of like certification and training to be able to offer that. 'Cause I also get like, you're not gonna get a pediatric dentist in every rural corner of every state. Like it's hard to get people to these little towns in Oklahoma and Missouri, let alone a pediatric dentist. Like there's just not enough of them that wanna go to those spots. So you gotta come up with a solution of some type, but you also, you don't wanna see kids getting hurt being sedated by underqualified people in a not ideal setting. Well, I mean, how far do patients travel to come see you? A long way is I'm sure the same, but two hours pretty easily this morning, several of them two hours plus, you know. Yeah, we always talk about access to care and I think there's two arguments that get thrown around a lot. One is, well, if I don't do it, nobody else will. So a lot of General Dentists kind of justify, hey, well, if I don't do it, nobody else will. And I think pediatric dentists sometimes we can do that. And I think that's like a fallacy in a lot of ways because I think there are people that will do it. Are there are solutions, but when we fill the void and don't make a need, then we're offering a suboptimal solution and then that becomes the norm. So it's like, I think sometimes we justify it. And then the second argument that a lot of people make is like, well, like a General Dentist, well, there are bad pediatric dentists too. And it's like, yeah, there are. It's just like when you have to go through training, you have to go through another hierarchy. Like it's the same getting into dental school. Like, yeah, there's bad dentists, but like you had to work hard to get into dental school. Yeah, there's bad pediatric dentists, but you had to work hard to get there and you had to do two additional years. So the likelihood of having a bad pediatric dentist is a lot lower than having a General Dentists working on kids do a bad job. So I think those are two common fallacies that we see. But I think there's also solutions to getting out to the rural community. - Yeah, I think a big one or an easy one for me, like some sort of loan repayment, I don't know where that money's gonna come from, but I will has a program where if you go to an underserved county as a General Dentist, you can get like 100 grand. You have to apply and it's a whole thing. But somewhere out there, if the billions of dollars, they can move a little bit around where there's a program or if each state could kind of have a program that incentivizes you if you go to a certain area and put in a certain amount of time, they'll just help you just knock out your student loans right away. I think when people get these half million dollar giant student loan debts, like that seems like an easy area to kind of incentivize people to not pile into the same, into Oklahoma City or wherever people don't. - I think the downfall to that, those then they go and repay their debt and they're like, "Peace out, I'm not out of here, yeah, I like people again." - Yeah, the wife was like, you know I was like, or you know, wife or husband's like, "I'm not living out in the boonies, you know, that's my life." - Yeah, you know, so when I was practicing, it was one of my attending when I was at the Children's Hospital in Colorado, they had a practice in Colorado Springs, but then they also had like a satellite practice out in like Canyon City. And they kind of had this model where they do some like, tell a dentistry and stuff. And it got me to thinking, and I think some of the DSLs try to do this where they try to do like a spoke and a hub and spoke design where you have a big office in a central city, and then you can have satellite offices. And my vision for helping rural Oklahoma is like, "Okay, I've got two offices. I'm trying to make these like bigger offices where I can have multiple docs working at the same time." But once we have enough docs, can we have a rural location where maybe each of us work one day a week? Like, I don't want to go out and live an hour and a half away in the middle of nowhere where there's more pounds of meth than people. But I'd go out there once a week and I'd help out, but it's like, well, if you have like six or seven doctors and you're like, "Hey, I'll go out there once a week." Can you all spread the love? Maybe we can all live in the city, but then go out to these rural locations and still keep the same quality of care and keep a group who are not isolated. I just feel like that's a much better solution, and a long-term solution where there's perpetuity rather than just a loan repayment where people they're there and then they book it, and then they sell their office to a DSO when they leave because their loan repayment's done. I think we need to think long-term about how these things keep lasting. - Yeah, that's a great solution. I write down notes whenever I'm done. - It's idealistic. I'll say that. I'm a very idealistic person. I think of it as hard-to-clap. - He's often theory a little bit, but at Phase Valley, it's a really good idea. You kind of rotate different doctors through some of these rural satellite clinics to try to help serve. - I think there's enough good out there. I think there are some amazing pediatric dentists and I get to work with the residents, and there's some amazing residents that would buy into this system and buy into this group where we're all helping each other out. We really could do that, and I think of pediatric dentists. If we work together, we're a little bit more collaborative. It's really not about the money. We're going to live good lives, but man, I really think about a legacy. Do you ever think about your legacy? What are you going to leave behind when people hear the name like "Case of Gats" and they're like, "Oh, man, like that guy." What did he do? What's going to stick behind him? I mean, I don't want it to be dentistry, but it's like, man, he impacted public health, or he impacted this community. I think about that a lot, and when I die and people hear my name, I want my kids to hear my name be like, "Oh, people really appreciated my dad "for what he did outside of dentistry." And I think we have such a huge opportunity. Why don't we do that as pediatric dentists more? - Yeah, it's a great parting advice, 'cause I was going to start signing a soft here, but that's a great way to wrap up an episode, like what's going to be your legacy, what are you going to leave behind? I don't know if I've thought about it at such a deep level, like you have, but I tell parents a lot often, the way that I know that I was a good dentist was when I'm gone down the road. Like every parent always says, "Oh, my dentist growing up, it was terrible and XYZ." Like if all of our patients were seeing now grow up and the rest of their lives are going to be impacted by how we treated them during their pediatric years. So 60 years from now, when we're in the dirt, they're going to be the patients now, are going to be old people, they'll be like, "Man, my doctor Mark, floss boss, pd." Isn't that your practice, your practice? - Yeah, that's it, floss boss, pd. - Yeah, he was awesome, he wore the coolest, he wore bluey shirts and he was so fun, I freaking loved my dentist. Even if you're dirtbagged the rest of your life, whatever, if you don't do anything else, but if you're at least like that good of a dentist, there's an impact there that has a ripple effect, like you change lives a lot of people doing that. So at least that alone has a win. - Something beyond like a shortage of stainless steel supply. - Yeah, yeah, for sure, for sure. Mark, let's say I'm going to wrap this up here because I got kiddos trickling in. But what if somebody wants to get in touch with you to learn about Oklahoma or talk about startup trans, your practice journey or DSO questions, can you leave us with some contact info here? - Yeah, like some email is [email protected]. Reach out to me, I'd love to chat. If you're doing, if you're building something, have questions, I am always happy to help. Even if you're going to set up shop right next to me, there's plenty of room for everyone, man. We should work together, if there's no reason it can be, we're ready to help each other out. - Yeah, I like how cordial and nice you are, that's great. I still genuinely hope somebody doesn't like open up on your doorstep this next year from that. - I don't think they're well, it's better to be friends, though, thank you for joining me, that's fun. We'll always need more good dentists here. - Yeah, all right Mark, well hey buddy, great talking to you, great catching up, and thanks for making it happen, I appreciate it. - Hey, thanks for your time, man, hopefully it wasn't too crazy. (electronic music) - Thanks for listening to the Bruce and Tiny Teeth podcast. Be sure to DM our host, Casey Gats, on social media, with any listener questions, comments, or tough clinical situations. We'll see you next week for another unfiltered episode.