Helping Healthcare Scale
Imagine you're friends with multiple CEO's of billion dollar organizations. You can call them anytime you like and ask them all that they've learned about real estate and investing, including some of their biggest mistakes.
That's the mission of this podcast, to teach the insider strategies used by the big guys to everyday healthcare operators in order to get access to the best strategies and real estate at the best prices.
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Helping Healthcare Scale
Tech and Finance: A New Era for Dental Service Organizations
Discover the future of dentistry as Dr. Sepand H, the visionary CEO and founder of Total Health Dental Care, redefines what it means to run a Dental Service Organization (DSO). From aspiring software engineer to groundbreaking dentist, Dr. H shares his journey and unveils a tech-enabled model that promises to enhance patient care. His revolutionary approach aims to seamlessly connect dentists and specialists, creating an exceptional patient experience that boosts both retention and profitability. Join us as Dr. H sets the stage for a new era in dentistry, challenging the limits of traditional practices.
Technology's transformative power takes center stage, illuminating a path forward for DSOs grappling with modern challenges like wage inflation and capped fees. Since 2021, embracing innovation has become a necessity, not a choice. Learn how advanced tech solutions can refine operational processes, allowing for better staff compensation and a more satisfying patient experience through automation and online services. Dr. H passionately advocates for native technology solutions tailored to the dental industry's intricacies, highlighting their potential to streamline operations and revolutionize business models.
Navigate the labyrinth of banking regulations and macroeconomic dynamics with us, focusing on their implications for the growth of DSOs. The conversation delves into the effects of the Dodd-Frank Act and the critical role of private equity in dental service expansion. With insights into potential interest rate changes and persistent wage growth, Dr. H discusses strategic financial planning to maintain healthy margins. By integrating technology and adjusting fees, DSOs can adapt and thrive amidst economic uncertainties. Tune in for a deep dive into the intersection of technology, finance, and dentistry, and leave with valuable insights for your own practice.
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I climbed that mountain, I realized that it's incredibly isolating being in a little shop and doing that for 30 years and retiring with your gold Rolex. That is not for me, and I thought to myself this is in 2011. How cool would it be if dentists and specialists were seamlessly together and we would hire other people to do everything we don't like. So we launched Total Health Dental Care in 2011.
Speaker 2:Man, you guys were early to the curve. The plan was to be multi-site at that stage, like essentially a DSO. Yeah, that was exactly the plan.
Speaker 1:And then what I really wanted to do is capitalize better patient care Austin. And what does that mean? I'll define it. So the traditional model is pretty good, right, the owner-operated model is pretty good in terms of the worm and fuzzies, and what I wanted to do is scale a better model of that on a much larger platform. So capitalizing better patient care means the better you treat the patient, the better experience you give them, the more money you make, and if I could be able to do that, I would influence the industry to follow suit and we would improve dentistry in the future. That means the next generation of DSOs are better than the owner-operator model.
Speaker 3:The goal of this show is to help healthcare organizations scale by leveraging real estate strategies and interviewing high-level healthcare executives in order to pull out lessons learned along the way. If you'd like a free site selection analysis from our team, visit us at wwwreuniversityorg and drop us a line.
Speaker 2:Hello, welcome back to another episode of Helping Healthcare Scale. I'm Austin Hare. Our guest today is Dr H. He's the CEO, founder and dentist at Total Health Dental Care. It's a tech-enabled DSO in the Bay Area. They've got 13 locations with three affiliates and they are a branded fee-for-service tech-enabled specialty and GP DSO. Dr H, thanks for coming on the show.
Speaker 1:Thank you, austin, super excited to be here. I think you guys do a fantastic job with your podcasts and I'm excited to be here as well. Also, just to let you know, I didn't try to wear a white shirt to match your white shirt. We're not having uniforms here, it's just we're both, I guess, into the white shirt.
Speaker 2:Yeah, that's funny. I noticed that when you hopped on it was not coordinated ahead of time, but that's really funny.
Speaker 1:Are you saying great minds think alike or dress alike?
Speaker 2:Yeah, yep, that's what it is. It's a sign. It's a sign that this is going to be a great podcast. Yeah, curious. I think, like your background is obviously pretty relevant to what we're going to be talking about today, which is just going to be a lot of the technology on the dental side and the DSO side. So maybe give us your background and how you got into this space.
Speaker 1:Sure, so I just I grew up in Menlo Park before Facebook moved in, so I was around, these been VCs and things got started. Then I went to college where I wanted to pursue software engineering or economy. I was really good with both of those and my sister was a dentist and she's SEP and I go by SEP shirt for SEPAN. You should really think about dentistry. She was a dentist, you could use business, you could use engineering, this and that. So I went into dental school. My natural talent was in engineering as well as economy. I have a pretty strong natural scale for those.
Speaker 1:But I went into dental school in Pacific and San Francisco because of my sister's encouragement. And it's interesting because I went in there really not knowing much about dentistry. I actually didn't even know what a crown was. And then there was all these other students who were like second generation dentists and they had a lot of training and this and that they were like in their happy place. They're like this is what I've built my whole life for and I was coming in there. I'm like, wow, I wonder how I'm going to do this.
Speaker 1:So I ended up really working really hard in dental school and when I got out I worked really hard to be a Tottenham.
Speaker 2:To be a what. And then we broke up for a second.
Speaker 1:You said you worked really hard to be a what A really good dentist like a highly skilled dentist, and so what ended up happening is, once I climbed that mountain, I realized that it's incredibly isolating being in a little shop and doing that for 30 years and retiring with your gold Rolex. That is not for me, and I thought to myself this is in 2011. How cool would it be if dentists and specialists were seamlessly together and we would hire other people to do everything we don't like. So we've launched Total Health Dental Care in 2011.
Speaker 2:Man, you guys were early to the curve. The plan was to be multi-site at that stage, like essentially a DSO.
Speaker 1:Yeah, yeah, that was exactly the plan. And then what I really wanted to do is capitalize better patient care, austin. And what does that mean? I'll define it. So, if you, the traditional model is pretty good, right, the owner-operated model is pretty good in terms of the warm and fuzzies, and what I wanted to do is scale a better model of that on a much larger platform. So capitalizing better patient care means the better you treat the patient, the better experience you give them, the more money you make. And if I could be able to do that, I would influence the industry to follow suit and we would improve dentistry in the future. That means the next generation of DSOs are better than the owner-operator models.
Speaker 1:Yeah, so, on that note, how would you define better patient care? I would define better patient care as patient retention. So, if you, it's just, it's the experience Like, it's the experience patients have, it's the warm and fuzzies, it's the wants to come back, and there is a lot of layers to that. There's always the clinical, there is convenience, there is value. There's a lot that goes into that and it's not easy. And if you are not having owner operators in the locations, what are you going to do to bring that value to the patient.
Speaker 2:Yeah, so when did you guys start realizing then, like how important the technology was behind it? Because there is, I think, more of a push for it lately. Everybody, we always think we're high tech the definition of that kind of changes as you go along because technology advances. So in 2011, were you focused on being very high technology, like leveraging a lot of technology back then?
Speaker 1:No, so we didn't really get into the tech game until 2021. Now I'm in the Bay Area, I'm in entrepreneur groups, I have friends who are in tech, but 2021, I had an epiphany that, like, technology is the way right, and so we really started getting deep into technology, both stacking it and building it natively, and it's been a really interesting journey and I'm excited to share that with you what I've gone through, wins and losses, and how it could help the industry.
Speaker 2:Yeah, I know we're talking off camera just about the issues that face. Dentistry in general is not being able to raise fees, like being capped by the insurance level, and if you not everybody accepts Medicare, medicaid or whatever. But it's like I know 2021, the return to work like that's when we really started seeing this wage inflation. So was it like that whole process that just got you thinking about that?
Speaker 1:Yeah, I hear a lot of ESOs struggling and I hear them struggling, and there is all those concerns about interest rates that have gone up and hey, wait, staffing is a huge issue and wage inflation is really, and I feel for them. Yeah, because if interest rates have gone up five percent and wages have gone up five percent and your margins were 15, guess what? It's now five. And so the reason why I bring up technology and also is when you have the right technology, you can pay your employees more, and if you pay your employees more, you need less of them, so your margins go up. And if you have technology that patients love, you can drop insurances, and if you could drop insurances, you could raise your fees to match what inflation is.
Speaker 1:And if you could drop insurances, you could raise your fees to match what inflation is. Independent of insurance is not easy to do and we don't have a lot of headcount. Yeah, so I think then, also to answer your question, the industry in whole complains about interest rates and wage inflations, but nobody's talking about the fact they can't raise their fees. Do you know any business model that can't raise their fees?
Speaker 2:No only health care.
Speaker 1:Yeah, and that's a problem. What do we do to fix that?
Speaker 2:Yeah, so let's talk about it then. What are the technologies? Because I think it's true, no-transcript technology for Sure.
Speaker 1:So let me go back to okay. I hear folks say, oh, technology is the solution. Big DSOs are very smart individuals, talented, they have the top-notch executives, but they're designed for finance and operations right. So there is a void there of adopting technology On the tech side. The dental space in the United States is a $224 billion industry with the market cap for technology being half a percent of that, maybe a billion or two billion. So it has a very small market cap. Where am I going with this? Austin? Where I'm going with this is DSOs aren't designed to create technology, but because the market cap for technology in the DSO space is so small, there's not enough players coming in. So people talk about yeah, that sounds great, but what kind of technology are they bringing in? And they're bringing in marginal improvement technology, technology that improves the space a little bit, and that's not enough to counter the wage, inflation, interest rates and fee cap that we have. So the solution is a tech-enabled DSO like mine that can do both. They understand the industry and also understand technology, where they can hire engineers and create or stack their own technology. So then, where am I going with this?
Speaker 1:Workflow automation you need technology that reduces the number of tasks that an employee has to do. And if you can reduce the tasks they have to do, they're more efficient, they can produce more and you can pay them more. And all of a sudden the staffing issue is gone, right, because now you're paying people really good wages, it's a good job, they're not going to call out as much and also they're going to be more productive, so you're going to be more profitable. And if you do the same thing on patient convenience, with technology, online scheduling, patient portal automation the patient's convenience people are willing to pay a premium for convenience, right. So the technology.
Speaker 1:So I'm going to I'm going off on a tangent here, austin, but the joke I have is in this company there was a $5 million coffee machine that broke and this company called an engineer to fix it. He came in, kicked the coffee machine and it started working again, and send them a bill for $50,000. And this company was outraged, like you just came in and kicked my coffee machine and you're charging me $50,000?. So the scientist said look, let me itemize why it's $50,000. I charged $50 for kicking your machine and I charged $49,950 to know where to kick the machine. And the joke being is like it's not just technology, but you have to know what kind of technology, where to put it to make the copy machine work.
Speaker 2:Yeah, I see a ton of software companies all the time at events that have booths and that sort of thing. But it's your point. Are you utilizing it the right way? Like it can be first of all, a little overwhelming and then, second of all, maybe even like incongruent, right, if you get a technology to do this and then you bring in another technology to do this. So is what you're saying that you are hiring developers to build your own technology that stacks on top of it, essentially stacks, and all communicates together effectively? Is that kind of like where you're getting at?
Speaker 1:Yeah yeah, native technology is exactly that and I think what I was going with at the market cap is the most technology companies that exist today, because the market cap is small, can't take risks If your market cap is small and you don't hit a home run. So really, the only person that can fix this technology issue is a small enough DSO that's tech enabled, that can take the risks to do technology that can improve workflow, automation, patient convenience.
Speaker 2:Yeah, it's going back to the wage inflation. When we have an inflationary environment, like something has to give, especially in an industry where you're just not able to increase rates as much as inflation. And so some people look at that and they, if you use automation to replace jobs, essentially the argument to that that some people make is like you're firing somebody in order to make more money off the other person that you're keeping on. And it's when I hear that it's just, it just feels so unsophisticated because if you don't change something then you're going to go out of business and nobody has a job. So it's like letting, like create, using technology to lower headcount, and especially when that results in being able to increase pay for the people that you keep is actually net positive for all of society. It's just so crazy that people would make that argument.
Speaker 1:Awesome. I couldn't agree with you more. And I'm going to piggyback on that and say look, if somebody is struggling, they're working full time and struggling to make ends meet. Are you really really hurting them by giving them opportunity to go pursue something else that might make them happy? And so what I'm getting at is look, we do have a lower head cap, but we pay more. We have hourly employees that own houses in the Bay Area and I'm incredibly proud of that. They work four days a week because they can make as much in as four days as five days. And you can't stop growth and if you have technology, you could really take care of your people.
Speaker 2:So let's go deeper on the technology. What is the actual technology that you guys are using? Is it proprietary just to your DSO, like you guys built it all in house, and what specifically does it do?
Speaker 1:It is proprietary, so I can't go into too much details, but like it does two things. The first thing is patient convenience. Right, like that's the most important thing You've got to create convenience. People do not like making phone calls. Do you enjoy calling a medical dental office? They don't pick up, they call you back. You don't pick up, you call them back just to get a cleaning.
Speaker 1:No, yeah line but has to be done well, online right. So it's not just having the tech, it's got to be good tech right. Usage is important. If users aren't using your technology, it's not it. Then there is is also just and I think more importantly automation in the office to reduce the number of tasks people are doing. So there is a lot that goes into a fee-for-service office. This might be 30 tasks.
Speaker 1:How do I take it from 30 to 15? And if I could take it from 30 to 15, my team members can move a lot faster and I need less people, better pay people, no turnovers I have very little team members turnovers. You have a lot of what? Very little in terms of team turnover. My team does not leave and you know why they don't leave, and I want to say I'm the best CEO ever. I'm not. They don't leave because I paid them really well and we're healthy. We don't have any issues that other DSOs have, and I wonder if there is an opportunity for DSOs to collaborate together on increasing this technology in their much bigger entity, in the hopes of my vision of capitalizing better here.
Speaker 2:Okay, so what do you mean? Like a collaboration with a larger DSO?
Speaker 1:Yeah, I think so.
Speaker 2:I think that's the solution Raising fees and lowering headcounts, those are the so you think that clients, patients, they'll be willing to pay higher fees in exchange for the convenience? Is that kind of the thesis? Absolutely, and that's what you've been doing Like. You've seen the proof of that.
Speaker 1:Let's just look at the other industries. Who here, listening to this podcast, doesn't use DoorDash or Instacart or Amazon? And all of those technologies are convenient technologies and people pay a premium for more technology. Convenience is key. Care is also important in the office, and that comes down to lower headcount, higher talented employees. So those are the directions that I think the industry needs to go Patient convenience, lower headcount technology.
Speaker 2:Yeah, that makes sense. Yeah, it is hard. I'm like it is. It's just crazy. Healthcare in general is just so crazy. Not just dentistry, but just going scheduling to see your annual checkup and your physician or whatever. But some people make it easier. Yeah, if you can go, if you could just go online and schedule an appointment and not have to talk to anybody, that does make it a lot easier. Because, to your point, it's like having a call nobody answers, or, oh my gosh, it's 5.01 when they closed at 4.59 and they don't open till 9 am, and so people are busy between 9 and 5. And, yeah, like it's just, there's so many hoops to jump through.
Speaker 1:And then, on top of that, pricing is just so trans or opaque, I should say, like you can't tell at all. So is there any part of that where the pricing model is more transparent? If it's a fee for service, yeah, I think there is again empowering the patient with convenience and you could do things where, hey, austin, we'll send you a text saying that you have $1,500 left on your insurance and you have a crown that is remaining right. You broke your tooth, you need a crown, and this is going to relax at the end of the year. There needs to be a technology that gives that convenience and information to the patient.
Speaker 1:And, yeah, I think being transparent with costs, the beauty of being able to raise your fees is healthcare is elastic. People don't realize it's not as price sensitive I'm an economist, right, so it's not as price sensitive as people think. And the key is, if you don't have the kind of experience and convenience and care, then yeah, you have to have low fees. But if you can fix that part of it with technology, then you can go ahead and increase your views.
Speaker 2:Yeah, that's interesting of it. With technology, then you can go ahead and increase your views. That's interesting. Okay, just one of the questions I'd like to ask is what's a belief that you've evolved your thinking on since starting this industry?
Speaker 1:I think that the Dodd-Frank Act really impacted dentistry in probably a positive and negative way. The negative of it is it really put a lot of covenants on lending to a business that is really strong cash flow business. What does that mean? That means that it prevented private DSOs from growing because at some point they weren't lendable because of the Dodd-Frank Act. And how much regulation Essentially the banks. The cost of regulating and defending this thing isn't worth the bank's time. So that could have fit into private equity coming in that doesn't have those regulations, and I think that's a thought that evolved. If dentistry was treated like the strong cash flow business that it is dentists don't really go broke right I think that there would be more private players and if there was more private players there'd be more innovation. If there was more innovation you know again, my vision is capitalizing better here there would be a chance to get there and that is a thought that has evolved.
Speaker 2:So what, yeah, Dodd-Frank specific. What is that specifically then, for everybody listening?
Speaker 1:We all know about the great recession and the counter to that was a lot of regulation on the banking industry that prevented, protected the consumers, right, you can't over leverage and you can't have predatory lending and this and that. But there's always a yang and a yang. The yang is the dental industry had no problems paying off their mortgage, right, but they were categorized in the same category of other cash flow businesses that are a lot riskier and because they fell in that category, they were basically unable to grow privately with that.
Speaker 2:Okay. Is it referring to the reserves required to be on hand at the banks?
Speaker 1:It comes down to once you hit a certain threshold with the banks usually $4 to $5 million of debt your loan becomes a lot more expensive because there's a lot more scrutiny by the SEC and other departments of the loan, and so for it needs to. So for the bank it just doesn't make sense to manage this note anymore. And unless they have really strict covenants and it's hard to have those strict covenants and grow If you have strict covenants where you have to make this much money I have this much cash flow, blah, blah, blah, blah and this much reporting right, the reporting is also like exhausting and you have to hire people for those reporting and you have to manage those reporting. Then how are you going to grow out privately? And then? So that's one of the things that I think I realized is, if lending was more flexible, there'd be more private players. If there was more private players, there'd be more innovation flexible, there'd be more private players.
Speaker 2:If there was more private players, there'd be more innovation, gotcha. So you're saying that, essentially, it's harder to grow a DSO because of this act, and so now, in order to grow, you have to partner with PE, because they're bringing in a lot more cash to the table to enable growth and relying less on bank debt. Is that what you're saying, exactly, but PE still uses bank debt. Is it just they're using less leverage, or what exactly Like how are they getting around it?
Speaker 1:I don't know that I don't have the amount of that pay grade, but in general PEs tend to be pretty wealthy, so there's a lot of lending that is way more flexible. Because of their financial position. They also can go with private banks. They also have LPs, so a lot of times they come in and buy a DSO cash, so then, and then they're able to stack on debt on top of that, because they bought it with cash. And then I think it's interesting because PEs now can have the opportunity to get into the tech enabled DSO side or, if they wanted to. I don't know if that's their game, though.
Speaker 2:Yeah. Yeah, it's hard to say. They definitely had to pivot a lot. The days of buy package sell are gone. You're not getting these crazy arbitrage multiples anymore, so it seems like they're going to have to be tech enabled right Like. It seems like they're going to have to really focus on how to create economies of scale and increase same store EBITDA margins one way or another. The arbitrage play just seems like it's too difficult right now.
Speaker 1:Yeah, and I'll be honest with you. I think interest rates are going to go down going forward in 25 and 26. I don't see that, but I don't see wages going down. Wages are going to continue going up and I think that the industry as a whole needs to know that the wages aren't going down. You're not going to go back to 2019. Wages and also the mindset of the employees have changed and that's not going to change back either. So tech is the only get. Tech and being able to raise your fees are the really the key metrics that can solve the growth in the ESO space.
Speaker 2:Yeah, yeah, there's a lot. I guess maybe we can talk about macroeconomics and the future of the economy, because I think we both agree the economy is going to continue to go up, but it obviously doesn't go up into the right in a straight line. It was interesting, like this couple of days ago, at the time of this recording, they announced the Fed rate cuts of like 25 basis point and market just had this massive sell-off. I think S&P dropped by three percentage points in one day because I think what happened is like people realized that the rate cuts weren't going to be as dramatic as they had hoped for right, they're like everybody's constantly having to change their predictions, like us too. When we looked at these rate cuts or sorry, the rate hikes back in 2022, when they started happening, first of all, I thought the rate hikes would have happened way sooner than they happened. It took way too long. And then, second of all, I thought the rate cuts would have happened way sooner than they happened. It took way too long. And then, second of all, I thought the rate cuts would have happened way sooner than they happened. So, like when we were underwriting deals, we thought they'll be high for a year and then they're going to start to come back down and I think they'll probably average within 18 months. We'd think they could be in the middle of where they were at the lowest and where they were at the highest, so we didn't ever think they'd get back down to. Obviously, fed's not going to go all the way zero, which means that you could get long-term debt for three to 4% on commercial real estate or residential real estate, but maybe they'll go to two, right, and then we could be at like 5%. Interest rates between five and 6% is what we were thinking, but it's just taken so long to do that.
Speaker 2:Look, the economy is obviously still growing. The markets are still hitting all-time highs, so maybe there's something to say about that. But there's a whole you have to. I think everybody has to become a little bit of a macro economist these days, because you have to be balancing so many things Like we gotta be thinking about okay, what are interest rates gonna be doing? How is that gonna affect if I'm doing acquisitions or if I wanna even just buy a house, like it's going to happen to the housing market?
Speaker 2:How is that going to affect the labor rates? Because if you open up a new office and that's your interest rates. They're high right now. That labor is going to increase, then you got to be very confident that the economy is going to increase as well, that we're not going to go into a massive recession, because if we do, now all your costs are way up and then we go into a recession. Consumer spending just completely drops. You're going to be screwed, right. So there's a lot of variables. I think like in short, both of us think in general, the macro is looking good, but it's not going to be a straight line. So what are your thoughts on that?
Speaker 1:Yeah, just to reiterate. So what you're saying is look, the economy is not improving as fast as, or the interest rates are not going down as fast as everybody wants. And what do we do? I think, like some of the services you provide, competition analysis and picking the right locations incredibly important but I think you also set the bar where your margins are going to be incredibly high, so it doesn't matter what interest rates are, and you can do that by setting fees and having technology. So if you're going to be opening up these de novos or acquisitions, hey, if I'm dropping 25% margins, I don't really care my rent, I don't care about my mortgage, and I could do that. Instead of having a three-person front desk, I could have a one-person front desk and I could pay them really well, and I could pay them really well, and I think that's where the technology comes to play is, you don't really need this many people. One of the key KPIs that we track is revenue per employee, and that's really important. Now can you guess what Google's revenue per employee is? Austin?
Speaker 2:Oh gosh, it would have to be. I don't know Like it sounds, I don't know. I'm just going to throw out a random number and say a million dollars. I don't know.
Speaker 1:Yeah, so it's actually above that. So it's a way it's above, it's way above a billion dollars, and that's why they get free lunches. I'm going to give you lunch.
Speaker 1:I'm going to give you a workout, I'm going to give you whatever you want and that's what. And so that's one of the key trackers on how are we doing with technology is revenue per employee, because it really tracks productivity. Ours is at 250, $250,000 revenue per employee. My goal is to reach 300. And I think that is a kind of a way for people to get into the real estate side and still have a margin of error where it doesn't matter if the interest rates are still too high and the wages are still going up, because you have a buffer. Yeah.
Speaker 2:Yeah, that's good.
Speaker 3:Yeah.
Speaker 2:Something's got to give somewhere right and I think that's the most common physical place to go to Utilizing technology lower wages, like not wages, but like lower payroll count, like headcount, and go all in on that as we're getting close to the time that we got, is there anything that you want to talk about that we didn't get a chance to talk about? I was really passionate about fees and technology.
Speaker 1:I think we've exhausted that, Austin, so that's about it. I would just let people know that I am really passionate about the dental industry. I care about it. I love dentists, I love the team members, I love DSOs. I love the private practices. If anybody really wants to talk about what we discussed here, if they can reach me I think texting I know it's unusual is the easiest way 415-830-1588. If you want to email me, it's really long. It's drhokmabadi at totalhealthdentalcarecom. That's D-R-H-O-K-M-A-B-A-T-I at TotalHealthDentalCarecom.
Speaker 2:Okay, great. Yeah, I appreciate it. It's been really helpful. Thanks for coming on the show sharing these things, sharing your ideas and, yeah, I hope people reach out who want to collaborate.
Speaker 1:Absolutely, austin. Yeah, thanks for hosting me and happy holidays.
Speaker 2:Happy holidays.
Speaker 4:If you need help finding the perfect location for your practice or you're ready to invest in commercial real estate, email us podcast at leadersreecom or go to leadersreecom and fill out our form. See you next time.