Dental Practice Transition E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Dental Practice Transition: A Practical Guide to Management, Second Edition, helps readers navigate through options such as starting a practice, associateships, and buying an existing practice with helpful information on business systems, marketing, staffing, and money management.
- Unique comprehensive guide for the newly qualified dentist
- Covers key aspects of practice management and the transition into private practice
- Experienced editorial team provides a fresh, balanced and in-depth look at this vitally important subject
- New and expanded chapters on dental insurance, patient communication, personal finance, associateships, embezzlement, and dental service organizations
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Veröffentlichungsjahr: 2016
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CONTENTS
Cover
Title Page
Copyright
Contributor List
Preface
About the Companion Website
Part 1: An Introduction to Practice Transition, Dental Practice Financial Statements and Practice Financial Analysis
Chapter 1: Introduction and Overview
Career Choices
The Current Market and Its Implications for You
The “Bermuda Triangle” of Practice Transition
Selecting Key Advisors
References and Additional Resources
Chapter 2: Financial Statements
Types of Financial Statements
Using Financial Statements
References and Additional Resources
Chapter 3: Practice Financial Analysis
Dental Office Financial Analysis
Dental Practice Costs
Financial Analysis: Quantitative Measures of Quality Management for a General Dental Practice
Practice Analysis
Application to Associateships and Practice Purchase
References and Additional Resources
Part 2: Ownership: Business Planning, Practice Valuation, Dental Equipment, Buying/Buying into a Practice, Starting a Practice, Financing a Practice, and Business Entities
Chapter 4: Business Planning: From the Perspective of the Dentist and the Banker
The Management Process as a Foundation for Planning
What Is a Business Plan?
Business Plan Format
Elements of the Plan
Resources for Business Plans
Key Points
References and Additional Resources
A Sample Business Plan (Figure 4.3)
Chapter 5: Understanding Practice Valuation
Introduction
Overview of the Process
Appraisal Methods
Factors Affecting Practice Value
Historical Performance versus Future Earnings
Other Issues in Practice Appraisals and Sales
Valuation Exercise
Conclusion
References and Additional Resources
Chapter 6: Dental Equipment
Tips on Buying New Equipment
What to Look for in Used Equipment
Valuation of Used Dental Equipment/Determining Fair Market Value
Maintaining Equipment
Final Helpful Hints
References and Additional Resources
Chapter 7: Buying/Buying into a Practice
Choosing the Right Location
Deciding to Buy out or Buy into a Practice
Due Diligence
Financial Statements and Tax Returns
Accounts Receivable
Existing Equipment Leases
Financial Forecasting
Common Transactions
Contracts
Key Points
References and Additional Resources
Chapter 8: Starting a Dental Practice
“I Want to Be My Own Boss”
Are You an Entrepreneur?
Other Considerations
Step-by-Step Process for Starting a Practice
References and Additional Resources
Chapter 9: Financing a Practice
Introduction
Financing Dental Transitions: The State of the Industry
Historical Perspective
Preparing for a Practice Acquisition Loan
Preparing Your File for a Commercial Lender
Understanding the Commercial Lender
Seller Financing
Local Bank
SBA Loans
Specialty Lenders
Loan Brokers
Questions to Ask Potential Lenders
Analysis of the Buyer
Analysis of the Practice
Loan Terms, Rates, and Typical Conditions
How to Maintain an Excellent Relationship with a Lender
Assessing Your Future
Practice Acquisition
Practice Start-Up
References and Additional Resources
Chapter 10: Business Entities
Sole Proprietorship
Corporations
Partnerships and Limited Liability Companies: An Overview
Description and Ownership
Necessary Documentation
Operational and Management Aspects
Tax Issues
Liability Issues
What Is Right for You?
References and Additional Resources
Part 3: Business Systems and Related Issues: Incorporating Technology, Dental Fees and Financial Policies, Dental Benefits, Appointment Scheduling, Compliance, and Embezzlement
Chapter 11: Incorporating Technology
Introduction
Choosing a Technology Partner
Evaluate Current Technology
Budget for Technology
Business Continuity
Computer and Networking Equipment
Digital Dentistry
Practice Management Software
Communication Options
Compliance and Security
Patient Entertainment and Education
Marketing Your Practice
Making Wise Investments
Conclusion
References and Additional Resources
Chapter 12: Dental Fees, Fee Setting, and Financial Policies for Patients
Introduction
Fee Schedules and Definitions
Why Do Dental Practices Need to Increase Fees?
Disturbing Trends
Factors that Influence Pricing
When to Raise Fees
How to Raise Fees
How Much to Raise Fees
Economic Indexes that Influence Fee Setting
Practice Purchase and Fee Schedule
Discounting Practice Fees
Discounting of Fees and Dental Benefits
Impact of Fee Increases
What Is UCR?
What are Percentiles?
A Benefit Provider Says My Fees are too High: Are They Right?
Relative Value Unit Pricing
Definitions
Why Financial Arrangements are Necessary
Account Registration Form
Disclaimer
Importance of Cash Flow
How Much Can You Afford to Finance?
Credit Cards
Utilizing Collection Agents
Summary
Book Companion Website
References and Additional Resources
Appendix A: Payment Policy Acknowledgement Sample
Appendix B: Financial Policy Worksheet (With Recommended Policies)
Chapter 13: Dental Benefits
Dental Benefits Overview
Publicly Funded Dental Benefits
Commercial Dental Benefits
Commercial Dental Plan Models
Commercial Dental Benefit Plan Types
Structure of Commercial Dental Benefit Plans
Participating Provider Organization (PPO) Obligations
Submitting Claims
An Overview of Dental Benefits
A Glossary of Dental Benefit Terms
References and Additional Resources
Chapter 14: Appointment Scheduling Strategies
Appointment Scheduling Policy and Philosophy
Types of Appointments
Units of Time
Disinfection and Preparation Time
Time Units by Procedure
Scheduling by Provider
Type of Procedure
Sequence of Procedures
Variability of Provider's Work Habits
Patient Preferences by Provider
Integrating Appointment Scheduling with Other Business Systems
Well-Balanced Patient Load
First-Time/New Patient Appointments
Children
Cash and Emergencies
Filler Appointments
Over-the-Counter Follow-Up Appointments
Getting It on the Books
Understanding Patient Behaviors
Telephone, E-mail, and Internet Appointment Scheduling
Confirmations
Recalls
Patient Account Balances
Laboratory and Preparatory Results
Who Is Responsible for Scheduling?
Computerized and Paper Appointment Schedules
Computer Interactive Scheduling/Web-Based
Completing an Appointment Unit
Chair-Side Scheduling
Accessing and Monitoring Schedules
Appointment Scheduling Maintenance
Replacing Rocks with Pebbles
Keys to Productive Scheduling
References and Additional Resources
Chapter 15: Compliance with Government Regulations
What Is OSHA?
Walking and Working Surfaces
Means of Egress
Noise Exposure
Ventilation
Nonionizing Radiation
Hazardous Materials
Personal Protective Equipment (PPE)
Put On:
Take Off:
Medical and First Aid
Fire Safety
Electrical Safety
Employee Medical Records
Ionizing Radiation
Blood-Borne Pathogens
Hazard Communications
Workplace Violence
OSHA Compliance and Inspections
Sexual Harassment
What Is HIPAA?
CDC Guidelines
Government Agencies Unraveled
References and Additional Resources
Chapter 16: Understanding Embezzlement
Introduction
What is Embezzlement?
So Who are These People and Why Do They Steal?
The Relevance When Purchasing a Practice
Controls are Ineffective
A Crime of Navigation
Daily Balancing is Impotent
Is Embezzlement Therefore Inevitable?
Avoid Hiring Mistakes
What About Existing Employees?
Expense Fraud
Theft of Revenue: The Biggest Problem
How Embezzlers Act
Can My CPA Find Embezzlement?
What to Do (and What Not to Do) If Embezzlement is Suspected
And What If I Catch a Thief Red-Handed?
Investigators
Maximizing “Net Recovery”
Sources of Financial Recovery
The Justice System
Conclusion
References and Additional Resources
Part 4: Marketing and Patient Communication
Chapter 17: External Marketing
The New Economy
SmilePalooza Is Born!
Differentiate or Die
The Battle for Your Mind
Build Your Brand
Key Online Brand-Building Strategy
Top Offline Brand-Building Strategies
Newsletters
Card Campaigns
Public Relations Enhanced Through Press Releases
Radio Show Host
Speak at Seminars
Write a Book
References and Additional Resources
Chapter 18: Internal Marketing and Customer Service
Marketing and Customer Service: How Do They Relate?
Internal Marketing
The Three Levels of Patient-Friendly Customer Service
Excellence in Communication Skills
Asking for Referrals
First Impressions Count
The Welcome Packet
Morning Huddle
Portraying a Professional Image
Guidelines for Dental Dress for Success
The Significance of the Team to the Patient
Definitions of Patient Service
References and Additional Resources
Chapter 19: Chairside Communication with Patients
Goals of Communication
Communication Strategies
Word Choice
Suggested Scripts
Management of Anxious, Fearful, and Phobic Patients
Fear
Pain Management
Special Needs Patients
Book Companion Website
References and Additional Resources
Part 5: Associateships and Dental Support Organizations
Chapter 20: About Associateships
Types of Associateships
Purpose for Associateship
Advantages/Disadvantages
Making the Connection
Define Success
Win-Win
Evaluation of a Practice
Compensation Package
Failure
Associateship Contracts
Conclusion
Acknowledgments
References and Additional Resources
Chapter 21: Dental Support Organizations
An Evolving Industry
DSO Models and Processes
The Present and Future of DSOs
References and Additional Resources
Part 6: Managing Staff: Human Resources/Compliance, Managing Dental Teams, and Staff Meetings
Chapter 22: Human Resources and Employment Compliance
An Introduction to Employment Law
An Introduction to Human Resources
Foundational Elements
Foundational Element: A Policy Manual
Foundational Element: Job Descriptions
Foundational Element: Personnel Files
Recruiting
Performance Management
Preventing Sexual Harassment
Tips on Dismissing Staff Members
Final Note/Conclusion
References and Additional Resources
Chapter 23: Managing Dental Teams
Before You Hire Anyone, What You Must Know
How to Locate and Recruit the Best Staff for Your Practice
Sample Employment Ads
Telephone Screening
First Interview
Questions About His or Her Most Recent Position
Questions About His or Her Other Work Environments
Questions About His or Her Personal Effectiveness
Second Interview/Skills Assessment and Lunch with Staff
Questions About Philosophies
Welcoming Your New Employee to Your Practice
Job Descriptions
Buying a Practice with Existing Staff
Training Employees
Employee Evaluations
Raises
Motivating and Appreciating Employees
How to Handle Challenging Staff Members: Focus on the Behavior, Not the Person
Disciplinary Process Leading to Staff Dismissal
References and Additional Resources
Chapter 24: Staff Meetings
Staff Meetings = Empowered Team = Delighted Patients
Morning Huddle: 15 Minutes Before the Start of Each Day
Monthly Team Meeting
Length and Frequency of Team Meetings
Moderator for the Staff Meeting
Getting Started: What to Do If You Do Not Already Have Monthly Staff Meetings
Other Ideas for Staff Education Topics
Book Companion Website
References and Additional Resources
Part 7: Money Management: Insuring a Practice; and Personal Finance, Investments and Retirement Options
Chapter 25: Insuring a Dental Practice
Insuring a Dental Practice
Health Insurance
High Deductible HSA Qualified Health Plans
Deductible Plans with Coinsurance
Deductible Plans with Co-Pays and Co-Insurance
Dental and Vision Insurance
Disability Insurance
Business Overhead Expense
Life Insurance
Protecting What Belongs to You
Insuring your Building
Insuring your Business Personal Property
Business Interruption
Policy Deductibles and Co-Insurance
Ancillary Policy Coverages
Flood and Earthquake
Protecting You the Dentist from Others
Workers Compensation
Employers Liability
Workers Compensation Policy Audits
General Liability Insurance
Umbrella Policies
Professional Liability Insurance
Claims Made and Reported Policy Forms
Occurrence Policy Forms
Employment Practices Liability Insurance
Cyber Liability Insurance
Identity Theft Plans
Summary
References and Additional Resources
Chapter 26: Personal Finance, Investments, and Retirement Options
Finance
Building Wealth
Budgeting Process
Exit Strategies
Summary
References and Additional Resources
Books
Websites
Index
End User License Agreement
List of Tables
Table 1.1
Table 2.1
Table 2.2
Table 2.3
Table 2.4
Table 2.5
Table 2.6
Table 2.7
Table 3.1
Table 3.2
Table 3.3
Table 7.1
Table 7.2
Table 7.3
Table 7.4
Table 7.5
Table 7.6
Table 7.7
Table 7.8
Table 7.9
Table 8.1
Table 8.2
Table 9.1
Table 10.1
Table 13.1
Table 14.1
Table 14.2
Table 14.3
Table 19.1
Table 20.1
Table 23.1
Table 23.2
Table 23.3
Table 24.1
Table 24.2
Table 24.3
Table 24.4
Table 24.5
Table 26.1
List of Illustrations
Figure 1.1
Figure 1.2
Figure 3.1
Figure 3.2
Figure 3.3
Figure 3.4
Figure 3.5
Figure 4.1
Figure 4.2
Figure 4.3a
Figure 4.3b
Figure 4.3c
Figure 4.3d
Figure 4.3e
Figure 4.3f
Figure 4.3g
Figure 4.3h
Figure 4.3
Figure 6.1
Figure 6.2
Figure 6.3
Figure 6.4
Figure 7.1
Figure 7.2
Figure 8.1
Figure 8.2
Figure 8.3
Figure 8.4
Figure 11.1
Figure 16.1
Figure 18.1
Figure 18.2
Figure 20.1
Figure 20.2
Figure 20.3
Figure 24.1
Figure 24.2
Guide
Cover
Table of Contents
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Dental Practice Transition
A Practical Guide to Management
Second Edition
Edited by
David G. Dunning, Ph.D.,
Professor of Practice Management
Department of Oral Biology
University of Nebraska
Medical Center College of Dentistry
Lincoln, NE
And
Brian M. Lange, Ph.D.,
Professor of Behavioral Science
Department of Oral Biology
University of Nebraska
Medical Center College of Dentistry
Lincoln, NE
This edition first published 2016 © 2016 by John Wiley & Sons, Inc.First edition first published 2008 © 2008 by John Wiley & Sons, Inc.
Editorial offices
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1606 Golden Aspen Drive, Suites 103 and 104, Ames, Iowa 50010, USA
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
9600 Garsington Road, Oxford, OX4 2DQ, UK
For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book, please see our website at www.wiley.com/wiley-blackwell.
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-1-1191-1975-6/2017].
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or website may provide or recommendations it may make. Further, readers should be aware that Internet websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data
Names: Dunning, David G., 1958- editor. | Lange, Brian Mark, editor.
Title: Dental practice transition : a practical guide to management / editedby David G. Dunning and Brian M. Lange.
Description: Second edition. | Ames, Iowa : John Wiley & Sons, Inc., 2016. |Includes bibliographical references and index.
Identifiers: LCCN 2016016542 (print) | LCCN 2016017184 (ebook) | ISBN9781119119456 (pbk.) | ISBN 9781119119463 (pdf) | ISBN 9781119119470 (epub)
Subjects: | MESH: Practice Management, Dental | Economics, Dental | PracticeValuation and Purchase | Dentistry
Classification: LCC RK58 (print) | LCC RK58 (ebook) | NLM WU 77 | DDC 617.60068–dc23
LC record available at https://lccn.loc.gov/2016016542
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Contributor List
Alderman, Bradley, D.D.S., Dental Practice Owner, Lincoln, NE
Anderson, Ronda, Hu-Friedy, Iowa/Nebraska Regional Account Manager, Louisville, NE
Boartfield, Rebecca, Human Resource Consultant, Bent Ericksen & Associates, Eugene, OR
Callan, Richard, D.M.D., Ed.S., Associate Professor and Department Chair, General Dentistry, College of Dental Medicine, Georgia Regents University, Augusta, GA
Crist, Ross L., D.D.S., M.A., M.S., Dental Practice Owner (orthodontics), Sioux Falls, SD
Cumby, Dunn, D.D.S., M.P.H., Chair, Division of Community Dentistry and Dental Services Administration, University of Oklahoma, College of Dentistry, Oklahoma City, OK
Dunning, David G., Ph.D., Professor of Practice Management, Department of Oral Biology, University of Nebraska Medical Center College of Dentistry, Lincoln, NE
Harris, David, M.B.A., C.P.A., C.M.A., C.F.E., C.F.F., Chief Executive Officer and Embezzlement “Guru,” Prosperident, Halifax, Nova Scotia, Canada
Heller, Eugene, W. D.D.S., Vice President, Henry Schein, Inc.; Vice President, Professional Practice Transitions Division, Woodstock, GA
Itaya Lisa, E., D.D.S., Associate Professor and Group Practice Leader, Department of Dental Practice, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA
Kirsch, Amy, R.D.H., Founder and President of Amy Kirsch & Associates, Centennial, CO; Member of the Academy of Dental Management Consultants; Formerly a Senior Dental Consultant with the Pride Institute
Lange, Brian M., Ph.D., Professor of Behavioral Science, Department of Oral Biology, University of Nebraska Medical Center College of Dentistry, Lincoln, NE
Lyon, Lucinda J., R.D.H, D.D.S., Ed.D., Associate Professor and Chair, Department of Dental Practice, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA
Madden, Robert, D.D.S., M.B.A., Dental Practice Owner, Littleton, CO
Nadershahi, Nader A., D.D.S., M.B.A., Ed.D., Interim Dean, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, CA
Neumeister, David, D.D.S., Dental Private Owner, Brattleboro, VT
Opp, Darold, D.D.S., Dental Practice Owner, Aberdeen, SD
Shea, Gavin, Senior Director Sales and Marketing, Wells Fargo Practice Finance, Pleasanton, CA
Smith, Tyler, D.D.S., Dental Practice Owner, Omaha, NE
Spitsen, Jim, Insurance Broker and Consultant, Harold Diers & Company, Lincoln, NE
Strasheim, Kristen, R.D.H., Amertias Group Customer Connections and Operations, Manager Dental Consultant Review, Lincoln, NE
Terronez, Thomas, Chief Executive Officer, Medix Dental, Bettendorf, IA.
Twigg, Tim, Owner and President, Bent Ericksen & Associates, Eugene, OR; Board Member, Academy of Dental Management Consultants
Wacker, Mike, Equipment Specialist, Benco, Omaha, NE
Webb, William “Dana”, Co-Founder and Financial Advisor, Fortress Wealth Advisors, Omaha, NE
Wiederman, Arthur S., C.P.A, C.F.P, Wiederman & Associates, Tustin, CA
Willis, David O., D.M.D., M.B.A., Professor Emeritus, Practice Administration and Health Policy Research, University of Louisville, School of Dentistry, Louisville, KY
Wolff, Steven C., D.D.S., Owner of ADS MidAmerica Dental Practice Sales, Raytown, MO
Workman, Rick, D.M.D., Founder and Chief Executive Officer, Heartland Dental, Effingham, IL
Preface
As anyone who has ever edited or written a book fully knows, this project could not have been completed without the untiring support of several vital people. Our lead department office staff member, Debbie Merritt, provided indispensable and timely support on many occasions. Key team members at Wiley, especially Teri Jensen and Catriona Cooper, also provided timely support throughout the project.
This book is designed so that each chapter “stands” in essence on its own. This means that the chapters are complementary and may even cover in a few cases the same or similar content in varying degrees of depth. Still, each chapter is intended to address a topic in ample fashion without relying on other chapters. Readers will certainly and intentionally glean much more from the book by reading chapters with augmenting content. Still, instructors in practice management may assign chapters individually or in combination, and readers may review individual chapters based on their needs and interests.
Profound market differences in dentistry and in cost of living typify the United States. For example, the value of dental practices may vary from 30–50% of average annual collections (or less) in sparse rural areas to well over 100% in highly competitive cities. Similarly, personal budgets vary greatly by region, especially owing to rent/mortgage expense. Internet sources may help understand some of the cost of living differences in various locations (for example, www.bestplaces.net—Sperling's best places—and city-data.com).
We are very grateful to all the chapter authors, all of whom have very busy schedules and thus basically participated in chapter writing “above and beyond the call” in normally hectic schedules.
We are also very appreciative of our chapter reviewers who invested significant time providing feedback while continuing their considerable regular work responsibilities:
Dr. Bradley Alderman
Ms. Ronda Anderson
Ms. Rebecca Boartfield
Dr. Richard Callan
Dr. Ross Crist
Dr. Dunn Cumby
Dr. David Dunning
Mr. David Harris
Mr. Drew Hinrichs
Ms. Amy Kirsch
Dr. Brian Lange
Dr. Lucinda J. Lyon
Dr. Robert Madden
Dr. Nader Nadershahi
Dr. David Neumeister
Dr. Darold Opp
Mr. Gavin Shea
Dr. Tyler Smith
Mr. Jim Spitsen
Ms. Kristen Strasheim
Mr. Tom Torronez
Mr. Tim Twigg
Mr. Mike Wacker
Dr. David O. Willis
Dr. Steven Wolff
Dr. Rick Workman
These individuals donated their time, literally, in order to provide valuable input to improve the already solid book chapters. Inasmuch as possible, writers were granted freedom of expression in writing style. Consequently, the reader will note variability in writing style from chapter to chapter. This is purposeful on our part as editors.
This book is not intended to, nor does it provide, legal, financial, investment or accounting advice. Readers are strongly encouraged to obtain the counsel of qualified attorneys, financial planners, accountants, and consultants for professional services.
Without God's grace, guidance and blessing, this project would not have been started or completed. Without support and encouragement from our families, especially our wives Kathy and Anne, this project would not have been accomplished.
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/dunning/transition
The website includes:
Sample worksheets and lists
All figures from the book
Video of a dental health morning huddle
How to access the website:
The password is the first word of
Chapter 14
.
Go to
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Part 1An Introduction to Practice Transition, Dental Practice Financial Statements and Practice Financial Analysis
Chapter 1Introduction and Overview
David G. Dunning and Brian M. Lange
This book is aimed at providing you with necessary concepts and perspectives for making practice transition decisions. The emphasis is on presenting sound ideas in a fair and balanced manner inasmuch as that is possible. We are not trying to sell you anything other than good information for decision making.
Assembling all that is necessary for practice transition in a single volume is a daunting task. More detail treatments are available for many of the topics addressed here (for example, see a partial list of American Dental Association [ADA] publications at the end of this chapter). Still, this book provides essential information not typically available in one book.
Career Choices
The future you see is the future you get.
Robert G. Allen
The major career question has already been answered. You are in dental school or have already graduated. For those still in dental college, questions often center on what area of dentistry: private general practice, private specialty practice, public health, military service, dental education, or are you one of the few that will join one or more of your relatives in “your” family practice? Our purpose here is not to duplicate an entire American Dental Association publication on career options, Roadmap to Dental Practice: The Guide to the Rest of Your Career After Dental School and Licensure. Rather, we encourage you to take a couple of cleansing breaths or deep sighs, and to take a step back and reflect on the process of making a career choice and some of the key issues in that process.
Most dental students in their first and second years are asking, now that I am in dental school, what is next? Questions begin to race through your mind. Where do I want to live? Or if married, where do we want to live? If I specialize, how does that affect where I can live? Do I want a metropolitan lifestyle, rural lifestyle, or something that allows a little of both? If you have or are planning a family, you find yourself asking about the best educational and social opportunities for your children. What values do you want your children exposed to day by day? For those who follow a faith-based lifestyle, where does God want me to be? Can I get student loans repaid, and should this, based on interest rates, be a slow or a quick repayment process?
The questions listed above are by no means an exhaustive list. They are meant to get you thinking about the relationships among you, your family, the location of your practice, and the type of practice (general, specialty, etc.). The matrix in Table 1.1 is meant to give you a starting point for your decision-making process. You can list across the top all the issues you need to consider in making a decision about the type of dentistry you want to practice and then see which area of dental practice best meets most or all of your criteria. Approach the matrix (decision-making process) with the following in mind:
Gather input from the people closest to you who will be affected by your decision.
What seems like a good idea in your second year of dental school may not seem like a good idea in your third year of dental school. Be flexible; at times, life can take a sharp turn.
It is called a decision-making process for a reason. Decisions, especially of the nature you are considering, require sound data and input, and take time. Be patient.
Table 1.1 Decision matrix.
Lifestyle We Want (e.g., Rural Area)
Values We Want
Loan Repayment
Educational Opportunities for Children
Close to Family
Housing We Want and Can Afford
List Other Important Considerations
General Dentistry
Specialty Practice
Military
Public Health
Dental Education
Dental Service
Management Organization
Institutional Practice (Hospital)
This question often arises when working with people making important decisions: what if I do all the right things, and I am comfortable with my decision. However, after being in the practice or another career path, I realize I do not like it? This is a challenging and multidimensional question with both a simple and a complex answer. The simple answer is that you can always move, although this may take some time depending on your situation. There is a demand for dentistry in many places. The complex answer is based on a series of questions:
What do you not like about the practice/career path?
What do you not like about the community?
Can anything be changed that would make you more at ease?
How does what you are experiencing differ from what you expected?
What would you do differently in choosing another practice/career path?
If you invest the time to go through the series of questions with family, and if you are in a position of working for (associateship) or with (partnership or buyout) another dentist, you may find out that you can eventually resolve the issues causing your discontent. However, if you are not able to resolve the issues causing your discontent by answering the questions above, you will be better prepared to decide on what you will do next.
Some points to remember when making decisions, adapted from McDaniels et al. (1995):
Decisions are tentative; you can change your mind.
There is usually no one right choice.
Deciding is a process, not a static one-time event. We are constantly reevaluating in light of new information.
When it comes to a career decision, remember you are not choosing for a lifetime. Choose for now and do not worry whether you will still enjoy it in 20 years. Life is fluid and change occurs.
There is a big difference between decision and outcome. You can make a good decision based on the information at hand and still have a bad outcome. The decision is within your control, the outcome is not. All decisions have an element of risk.
Think of the worst outcome. Could you live with that? If you could live with the worst, then anything else does not seem that bad.
Try to avoid either/or thinking: usually there are more than two options.
The Current Market and Its Implications for You
The dental market in its 21st century “adolescence to early adulthood” stage of life presents some unique opportunities and challenges for dentists and patients alike. These exigencies have profound implications for you. Let us consider the current age of dentistry and the present market as representing both the best of times and the worst of times as a background for this book.
The Platinum Age: Now Tarnished
The term “platinum age of dentistry” seems to have first been used as early as the spring of 2000 (Takacs 2000). So, why did people describe dentistry as being in the platinum age at that time? Much of the rationale hinges on the numbers, most of which you have probably already heard and so we will only point out the most critical ones.
Our population is living longer and is more likely than a generation or two ago to have had relatively good oral health. With fewer missing teeth and more teeth and supporting structures to be maintained and restored, there is, plainly speaking, more work to be done assuming patients have the means to pay for it and access to care to get the treatment done. In addition, research suggests that dentists now make more money per hour than physicians, although physicians make more annual income because of longer work hours (Seabury, Jena, and Chandra 2012). Finally, U.S. News and World Report ranked dentists as the No. 1 career in 2015 (http://money.usnews.com/money/careers/slideshows/the-25-best-jobs-of-2015/2), with vital practice team members, dental hygienists, not far behind at No. 5.
While these and other reasons may have justified dentistry being anointed as a “platinum age” for dentists for a time, we would remiss if we failed to mention that such is not the case for certain groups of patients. Patients lacking dental insurance, patients in some rural areas, and patients with lower incomes are all less likely to receive the care they need. So while dentistry may have enjoyed a platinum age for providers, it may have been more of an iron age for certain patient groups. Since you will be receiving much, we hope you will consider giving back much in whatever manner you are led to help close the gap in access to care. Options are many but include state Medicaid programs, nonprofit clinics, Missions of Mercy (volunteer weekends for providing care for the poor), and even providing free or discounted care or negotiated care based on bartering.
So, why now depict the platinum age as being tarnished? Several key variables are diminishing the “platinum age of dentistry,” even in light of dentists being named the No. 1 career. There are probably many variables at play here, but four in particular stand out.
First, the expenditures ($) for dental services appear to have flattened and may not rebound amidst the ebb and flow of economic conditions. Meanwhile, utilization (those going to the dentist for services) has increased for children and dropped for adults (Wall, Vujicic, and Nasseh 2012; Vujicic 2013). Further, and brace yourself for some sobering statistics, The total number of dental care visits in the United States, across all settings, decreased by 7% between 2006 and 2012. There were approximately 271 million dental care visits nationwide in 2006 compared with 252 million in 2012 (this means 19 million fewer dental visits in 2012 versus 2006). Over this same time frame, the US population increased by 5.3%, and the number of practicing dentists increased by 9.4%. As a result, average dental care visits per capita and per dentist decreased substantially. Even though more people now seem to have dental coverage of some kind—Medicaid, preferred-provider, and so on (see McGill 2014), patients still struggle to access care and still need some expendable income for any deductibles or co-pays.
Second, dental student debt has skyrocketed, prompting studies about its influence on recruiting students and impact on career decisions. As of this writing, average debt hovers around the $247,000+ area and is rising precipitously, with lower averages for public college graduates and higher for private college graduates (http://www.asdanet.org/debt.aspx). A debt of $225,000 at a blended 6.5% rate over 10 years results in a monthly payment of $2,555, without factoring in rather severe limits on the tax deductibility of student loan interest and income taxes owed on gross income. A recent graduate would need to earn on average $30,660 in annual income just to make a $2,555 monthly payment ($2,555 × 12). This indebtedness redefines the economic landscape for associateship positions and for obtaining practice purchase loans (study the related chapters on these topics—especially Chapters 3, 20, and 21).
Third, new dental colleges have been and are being created, and this may eventually saturate the market with an excess number of providers, especially in some markets (see Solomon 2015a, 2015b).
Fourth, decreased reimbursement schemes from some dental insurance companies are putting increased pressure on practice profit margins, presenting an ongoing challenge to dentists (McGill 2014). Summarizing an aggregate data set, Boechler asserts that “although the dentists and hygienists are working more hours on average each month, their net production per hour and per patient represents a smaller percentage of the gross. This is due to the increased use of insurance as payment, leading to more adjustments and a smaller percentage of net production. Unfortunately, for dentists, with the ACA [Affordable Care Act]…this trend is likely to continue into the future.” In other words, dentists can expect to work longer hours and realize increasing pressure on profit margins. Peruse several related chapters in this book, especially Chapters 3, 12, and 13, for insights about practice profitability, dental fees, and dental insurance/benefits.
The Best of Times, the Worst of Times?
A particularly astute and famous quotation from Charles Dickens's A Tale of Two Cities accurately describes the current transition opportunities for the general practice of dentistry: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.” How do these literary observations relate to transitioning into private practice?
In so many ways, it is indeed the best of times. In spite of the “tarnishing” impact of the variables described earlier (such as debt and lower utilization levels), it is certainly not by accident that dentistry was ranked in 2015 as the No. 1 profession as already mentioned. The return on investment remains good at least for the foreseeable short-term future (Dunning 2015).
However, it is also, ironically, the worst of times in a sense. Why? Because blazing a career path is becoming increasingly complicated with unpredictable demand for dental services and the need to make student loan payments. There is a need, among other skills, to be able to objectively evaluate the options that are available in order to make an informed decision. Further, the word has now been widely broadcast: dental students will likely become wealthy in their lifetimes. This means that many individuals and corporations are, metaphorically speaking, circling above the heads of dental students, not waiting for them to die, but waiting for them to live out their careers and to share in the revenue stream! The need to be watchful regarding personal and business insurance, regarding practice transition concepts and processes, and regarding investing has never been greater. Refer to the chapters addressing these issues, including Chapters 25 and 26 on personal/business insurance and personal finance/investing.
Amidst this best of times and worst of times, a plethora of transition arrangements and models have emerged. We are, frankly, surprised at the way that some associateship arrangements and practice purchases are structured, particularly in view of student indebtedness. Still, there apparently is room in the competitive market for contracts that seem to be heavily biased in some ways for the owner-dentist. Some very competitive market conditions give the owner-dentist incredible negotiating positions that, in such a context, may warrant many fewer advantages for an associate position and much higher prices for practices. Some consulting firms market and implement their business models of transitioning practices across incredibly variable market conditions, causing others to scratch their heads and wonder how these models can work in such diverse markets.
One of the main purposes of this book is to provide for you some perspective of wisdom based on historically proven concepts so that you can sort your way through this best of times and worst of times, through this fog of a somewhat tarnished platinum age of dentistry. In the end, there may not be any absolutely and indisputably “right” way to structure an associateship experience or to purchase a practice. Nevertheless, there certainly are reasonable ranges within which these endeavors can be structured, and some of these will be more or less favorable to you. This, then, calls for you to be a very wise consumer with business acumen.
The “Bermuda Triangle” of Practice Transition
Transitioning from dental school or early career paths (military or public health) into private practice represents a tenuous activity in which opportunities can readily disappear into oblivion. Hence, the reference in the heading to the infamous “Bermuda Triangle,” where, according to folklore and myth, ships and planes have disappeared without a trace (see Figure 1.1). Regardless of the veracity of the Bermuda Triangle in history, as a metaphor the name helps us to focus on the particularly tender and easily tipped process through which recent dental graduates enter the business world by trying to start, buy, buy into, or become associates of dental practices.
Figure 1.1 The “Bermuda Triangle” of practice transition.
The three-dimensional triangle in the practice transition model includes these parties/sides: the dental student/graduate, the owner-dentist(s), and the advisors for both parties (see the model itself). Inside the model are the particular dynamics and characteristics of the practice that, depending on how they “load” with each party, can also readily sink the deal. For example, suppose a prospective buyer understood that the staff in a given practice would be staying after the purchase, only to discover that all the team members are leaving. Such information could easily sink the deal, as could discoveries related to the opinions of area dentists, overhead percentages, and so forth. Outside the model are the external variables influencing the practice, including the wider economic conditions such as unemployment, inflation, and interest rates.
Three specific principles undergird this model; principles that, admittedly, are themselves subject to debate.
Principle #1: No single party in the transition process should retain all of the power or control. We believe this principle is an equitable one. The dentist-owner, obviously, enjoys more “position power” than a prospective associate or buyer. Still, the interests of the latter cannot simply be ignored. Some sense of balance and mutual interest must be preserved for a successful transition to occur.
Principle #2: Each party has competing interests, and thus this process requires some degree of negotiation, ranging from making minor adjustments to standardized employment agreements to developing unique contracts. Sometimes individuals have interests that seem somewhat odd. These may arise from personal history. Occasionally, for example, an associateship contract will contain some very specific provision regarding a rather obscure circumstance that presented itself in a previous associate's employment (for example, thou shalt not approve the purchase of any dental supplies).
Principle #3: This process of negotiation can easily/readily “tip” or fall (sink into the ocean) if any party maintains an unreasonable bargaining position or an unreasonable stance. We are of the opinion that practice transitioning needs to major in majors rather than get tipped by relatively minor issues. It seems unwise to walk away from an associateship contract because of a dispute about who pays for malpractice insurance for 1 year or because of a disagreement about whether the practice is worth $500,000 instead of $530,000. It is our opinion that you do not walk away from a practice sale for $30,000 (though maybe you should certainly pause and get expert advice for $100,000!).
Let us explore the nexus of the triangle where competing interests meet. At juncture “A” reside the relationships and interactions between the dental student (or recent graduate) and the dentist-owner. The model sinks or stays afloat based on the relationships between the person in transition and practice owner(s). How do the personalities mesh the philosophies of practice, the values governing behavior, the type of dental services to be provided? Do these two parties agree on some fundamental concepts and principles to structure an associateship or a practice purchase?
At juncture “B” emerge the dynamics of relationships and interactions of the dental student or dentist in transition with his/her advisors and the advisors of the dentist-owner. Importantly, note that advisors here may be both formal and informal. Formal advisors could include transition consultants/companies, attorneys, accountants, lenders, faculty, and so on. Informal advisors include parents, other family members, friends, and classmates. How well (if at all) are the basic understandings negotiated between the student or dentist in transition and the owner-dentist communicated to the formal advisors? Does the consulting firm offer a flexible, efficacious business model to handle the transition as envisioned by both the student and the owner? May the student hire independent advisors in addition to the ones in the transition firm? Do spouses assert proper influence in the negotiation? We have seen cases where spouses exert incredible influence, potentially breaking the “deal” for relatively minor issues or by applying general business models inconsistent with the nuances of the dental market. Does a student agree with the philosophy/business model of the transition firm if one is involved? For example, some firms assert that they represent both parties (known as “dual representation”), is the student comfortable with this? Should a student have to pay an up-front fee to look at practices or an “earnest” payment to hold the final purchase until after graduation? Will the lender offer the money needed for the practice—and, if so, are there any liens against the practice?
The relationships and interactions of the dentist-owner with his/her formal and informal advisors and the student's advisors develop at juncture “C.” Does the owner-dentist communicate clearly to transition consultants the previously agreed-to basic understandings negotiated with the student? Unfortunately, the answer is often “no.” In other words, it is fairly common in transitions for the communication between the owner-dentist and his/her advisors to fail to include what the student and owner thought had been negotiated through several extensive conversations. This is often because the owner's advisor failed to edit a standardized employment agreement or utilizes a possibly inflexible approach to transition. Do the student's advisors offer what is perceived to be reasonable positions with respect to practice valuations or associateship contracts?
Inside the Triangle
Every dental practice has unique characteristics that make up the inside of the triangle. Some of the key “inside” variables include practice location, patient base (and its historical, current, and future dental needs), unique staff, the practice's office design (which can make life much easier or more difficult for the practitioner), technology, number of active patients, and financial information (see Chapters 2 and 3 on dentistry financial statements and key quality performance indicators for an excellent overview by Dr. David Willis). This inside picture of the practice needs to be understood, especially by associates intending to buy and by potential buyers. This is all part of due diligence. For example, a practice showing production of $510,000 and collections of $450,000 for the previous year creates a “due diligence opportunity” for you. Is this uncollected revenue and/or dental insurance adjustments”
Outside the Triangle
Outside the triangle are the external variables unique to the neighborhood, town/city, county, and state. Is the neighborhood older and established, deteriorating, or growing? What is the general population of the city/county, and how many general dentists are in practice? This information can be researched through a variety of sources as well as purchased from certain firms. Is the dental market highly competitive for patients? If so, practices will likely sell for much higher prices, comparatively. Two states may be separated by a mile-wide river. Yet this may be a great divide representing two distinct markets: one essentially saturated with third-party payers; the other, primarily fee-for-service patients. In addition, the wider economy, interest rates, unemployment, and inflation have incredible influences on any dental practice. In total, these external variables cannot be overemphasized.
Broadly speaking, the continued growth of group practices represents a fundamentally profound and ongoing shift in the national dental market and dental economy. This growing trend includes not only groups of dentists operating within the same building(s) with variously defined legal/business corporate relationships but also dental service organizations (a.k.a. “corporate dentistry”). Chapters 10 and 21 discuss, respectively, business entities and dental care organizations.
Some Common Pitfalls Causing the Triangle to Sink
In associateships:
Compensation offers from owners and/or expectations of would-be associates below and/or above typical norms.
Form of relationship: employee versus independent contractor. The IRS has a rigorous test for dentist-workers to qualify as independent contractors (search
www.irs.gov
). As you probably know, an independent contractor must pay his/her own share of social security tax AND that of the employer (just over 15% as of this writing).
Assignment of patients: is this fair and balanced? Does this match the compensation provisions of the contract to cover base pay or the “draw”? Patient assignment becomes particularly critical in practices with significant managed-care/third-party payers with resultant “adjustments” (reductions) in collections.
Buy-in provisions/process (timing, procedures, etc.).
Influence of third-party carriers on associate's compensation and on practice overhead and profitability.
Insufficient practice revenue for adding another dentist? Some argue that a single-dentist practice should have ∼$800,000 or more in collections before an associate should be hired.
Allocation of dental hygiene income: does the associate receive any income for supervising dental hygiene?
Restrictive covenant terms viewed as unreasonable.
An associate demonstrating weak interpersonal communication skills or marginal technical skills (Halley et al. 2008)
Dr. Eugene Heller (1999) also astutely details ten specific reasons for associateships failing; refer to his article listed in the references.
In purchases:
Practice value unknown or viewed as unreasonably high by associate and/or advisors.
Practice allocation of value seen as inaccurate (for example, a value of $10,000 for all equipment and supplies and a value of $375,000 for the goodwill or blue sky).
Can the buyer secure enough financing? Some lenders may cap the lending limit of new graduates.
Major change in the practice during the process of purchase (disability of owner, departure of staff, divorce of owner, etc.).
Practice projections that appear too good to be true from a transition consulting firm.
Undue and inappropriate influence of a key advisor (formal or informal).
Some Suggestions to Avoid Tipping the Deal
Study the dental market in the specific area. What do associates tend to earn in salary and benefits? What methods are used to evaluate practices? What is the extent of third-party involvement and reimbursement in the area? What are typical overhead/profit ranges? What are some ballpark figures for which practices typically sell in terms of percentages of revenue?
Chapter 4
covers the basics of practice valuation.
Identify your “nonnegotiables,” if any, in an employment arrangement and in a practice purchase. Are you willing to do prophies? What is your “bottom line” for income and benefits based on a detailed personal/family budget? How soon do you want to purchase the practice, and is this process in writing? What is the most you would be willing to pay for the practice?
Identify your negotiable positions: compensation level beyond minimums, practice value within a certain range, how the transfer will proceed with respect to patients, staff, and so forth.
Utilize a variety of advisors and weigh their input based on their expertise. Solomon advised, “Refuse good advice and watch your plans fail; take good counsel and watch them succeed” (Proverbs 15:22).
Make sure all items of importance are specifically documented in contracts and agreements.
Manage your credit rating; the higher your rating, the better. And while the “below which no loan” bottom threshold changes based on market conditions, generally speaking it is critical to maintain a credit rating higher than ∼665 as of this writing.
Selecting Key Advisors
Before you start the process of selecting advisors to help you through the maze of decisions that end up with you practicing dentistry, you need to answer this question: which advisors do I need? The list of professionals that you need to find the best practice fit for you is rather extensive. Most certainly your choice of practice (associateship, partnership, ownership) will influence the number of advisors and type of advisors you will require. However, before we dig deep into securing the best possible advice, do not overlook the invaluable input of any family members or family friends, particularly those in business or in dentistry. Conversations about the practice of dentistry with practitioners, especially family members, are most productive if you have a list of questions that reflect your goals. It is a good idea to verify information obtained about the practice of dentistry from family and friends with the perspectives of other trusted sources.
Two of your best resources in dental school are the faculty who teach practice management and the faculty who practice in the community. For most dental schools, talking to part-time faculty who maintain a private practice is one of your best resources for issues that face a dentist in private practice.
Faculty who teach practice management should teach you about or have references that can help you decide which advisors you should contact to help you achieve your practice goals. Many schools maintain a list of practice opportunities and dental practices for sale, as well as recommended advisors such as lenders and transition firms. Most practices may be within the state and region in which the dental school is located, and many listed practices are owned by alumni of the college. Nevertheless, your college's practices list is a good place to start.
Also, do not overlook the advice you can get from dental suppliers. Dental suppliers often know about dentists interested in selling their practices before the dentist goes to a broker or lists the practice. Most dental suppliers are happy to pass on information to prospective buyers in the hope of establishing a long-term business relationship.
The number and type of advisors that you use will depend on the type of practice opportunity you are pursuing. For example, if you are pursuing an associateship without the option to purchase, your banking, accounting, and tax needs will be different than if you are pursuing a purchase of a solo private practice or a future buy-in of a multiple-owner practice.
Let us examine in alphabetical order the advisors available to assist you in obtaining the practice environment of your dreams, or at least the practice environment that matches your goals. This is a basic list, not an exhaustive one. For example, architects are not discussed here and yet have a pivotal role in marketing your practice and lowering your stress level via insightful office design (Figure 1.2).
Figure 1.2 Unthank Design Group is an award-winning planning, architecture and interior design firm providing services exclusively to the dental professions. Dr. Michael Unthank is a dentist and registered architect and has designed over 2,000 dental and specialty offices throughout the world. (a) Dr. Davila's eight chair prosthodontic office in Tampa, Florida. This view of the treatment corridor illustrates the classical nature of Dr. Davila's heritage. (b) Drs. Glenn and Katzberg's office in Lincoln, Nebraska. Based on their theme for Genesis Orthodontics, a 42″ diameter globe is center stage in this contemporary new office.
Look at the list below as a menu from which you need to choose the advisors who will help you accomplish your goals:
Accountant/CPA
Attorney
Banker
Insurance broker
Investment counsel
Practice broker
There are key organizations specializing in dental services, including the Academy of Dental Practice CPAs (www.adcpa.org) and the Academy of Dental Practice Management Consultants (www.admc.net).
When looking for advisors, make sure they are skilled in working with small business/dental practices. If you use an advisor who does not deal with dental practices on a regular basis, you may end up paying to help educate the advisor and possibly pay again through lost income or legal entanglements because of outdated or inaccurate advice.
Selecting an Accountant
Consider, for example, what an accountant/CPA potentially has to offer:
Prepare periodic financial statements and annual audit reports
Assist you in analyzing your financial statements
