This episode’s specialty spotlight is Dental Service Organizations (DSOs) with guest Justin Puckett! Justin is the president of MB2 Dental and has 10+ years of experience in the dental industry. Tune in as we discuss how to navigate the corporate practice of dentistry, private equity in the industry, and operating a practice efficiently.
Listen to the full episode using the player below, or by visiting one of the links below. Below is the episode’s transcript which has been edited for readability. If you have any questions or would like to learn more, email us at email@example.com.
Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto. Legal issues, simplified through real client stories and real world experiences. Creating simplicity in 3, 2, 1.
Brad: Welcome back to another episode of the Legal 123s with ByrdAdatto. I’m your host, Brad Adatto with my co-host Michael Byrd.
Michael: Thanks Brad. As a business and healthcare law firm, we represent clients in multiple sectors and multiple specialties, especially healthcare. This season, our theme is specialty spotlight, where each episode we will visit about some of the nuances that can be found from a business and healthcare perspective in the various practice specialties.
Brad: Michael, I’m gonna make a demand. I would like a raise for co-hosting this podcast with you.
Michael: Perfect. I’ll double your salary.
Brad: Riley! You heard him. We have a guest here. I have two witnesses.
Michael: Yeah. I mean, in fact, Riley, you can just have Brad pick any multiple he wants of his current [00:01:00] salary and make it done since he gets paid nothing.
Brad: Oh, shoot. Well, apparently I need a better agent. I read an article release on how podcast guests are paying up to $50,000, just to appear on these popular podcast shows.
Michael: I know, I read it too. The critics are calling this process payola and think listeners in the article. The critics think these listeners should know about the promotional ties of guests and quotes that are kind of paying to jump on podcasts.
Brad: Yeah. And what was a shock to me for two reasons, first, apparently it’s extremely widespread. For many different shows and second we’ve been undercharging our guests for joining us.
Michael: Yeah. Well, if by undercharging, you mean we aren’t charging them. Yes, we’re undercharging them. That’s I think why they call them guests.
Brad: That’s a fair point, Michael. But, What also was surprising me is when I was speaking to Riley off air beforehand, and she was shocked to see the laundry list of [00:02:00] these extremely well known podcasters, which do actually require these payment. These are not some mom and pop ones. These are actually really well known podcasters.
Michael: Yeah, And when you read the article the guests pay the money. They know that, and they can push their product or their course or whatever it is that is kind of their underlying thing. They can get a two to three X return for appearing on these popular shows. So, the money quickly makes sense for them to pay it. Of course, I understand the critic point of view that it should be clear who is a guest and who’s actually kind of the, going back to the TV paid shows you see on Saturday mornings…
Michael: Where it has the line across the bottom, that this is a paid promotional content. I am curious, we have a guest in here. I am just kind of feeling a little awkward right now.
Brad: Yeah, it is kind of awkward for them right now.
Michael: How does all this pain to play, connect to our guests today?
Brad: Well, fair question. Today’s guest he’s a friend, former colleague, and I thought what [00:03:00] better way to start a new pay to play program by inviting him on and then invoicing him afterwards. So Michael let’s bring him on so we can start charging him.
Michael: I think that’s a wonderful idea. Our guest is our friend first and someone we’ve known for many years. Justin Puckett, Justin went to Texas A&M with a BBA and an MS in accounting, he went to the University of Houston law school, he practiced law before leaving to work at a dental support organization or DSO, as they say on the streets, he is now president of MB two dental, where he has been since 2013. He has a unique blend of experiences in corporate finance, public accounting and corporate law. And most importantly, Brad, he was a law clerk and an associate of you and me before you ran him off. I mean, before he left the practice of law.
Brad: He saw the light at the end of the tunnel on left. But, [00:04:00] Justin, thank you for joining us.
Justin: No, happy to be here.
Brad: Yeah. So we’re going to put you on the spot right away. How much money do you have in your wallet? Because as you can see audience members who are watching on our YouTube channel, we have this great new Payola jar here and all our guests will put money in it. Riley, our enforcer over here. She’s not going to let you leave until you put money, all your money, including pocket change in here.
Justin: Yep. Bad news is I am not a big cash guy but, you know, Venom, you can, like everything, go through my wife and Venom invoice her and she’ll take care of that one.
Brad: So that’s the jar that you have to do. So I guess the second question is probably what everyone in the audience really wants to know is how much better was it to work with me than Michael?
Justin: Epitome of a loaded question.
Justin: I would say obviously the jokes were better, I will give you that. I think the freedom with Michael was unlimited. So, that’s where [00:05:00] you know, it’s the epitome of going to dad and going to mom.
Brad: Not the first time I heard that one.
Michael: Yeah, Brad does not like being called mom by the way. Okay, well, let’s get started. We mentioned dental support organizations earlier. Can you just kind of introduce what is a DSO?
Justin: Yeah, DSO, like you said, it’s a dental support organization and I think it’s a fluid term. I mean, even when I got into dental about 10 years ago, there were MSOs and DPO’s, but I think essentially it’s an organization that is designed to help clinicians, in this case, dentists, with everything that you can imagine, that’s not clinical. That can be everything from accounting, legal, finance, IT, compliance, marketing, etc. With the very simple goal, which is if you could take that off their plate, they can focus more on clinical deliver, [00:06:00] better patient care in turn will result in better financial results as they’re just focusing on what they’re good at.
Brad: And so when you left us, abandoned us, and left me just to hang out with Michael, which was awful, by the way. Tell me, when you first stepped in switching over to the light and working inside one of these DSOs, what were some of the first things you started noticing right away?
Justin: Yeah. I mean, the first thing I noticed was originally, the lack of complexity. If you’re comparing it to a baseball game, the first or second inning we, no one, even, you know, we’d go to our annual conference, which called the DSO. There was, the first one I remember going to, about 40 people, wow. Last year there were like 2,600, you know? I mean, so you’re kind of writing the playbook a little bit. In a sense, I mean, if you look at it from a financial point, I think in 2013 there were about eight to 10 private [00:07:00] equity-backed DSOs. And now I think the count is like 160. So, that was part of the biggest thing is just. It was so early innings trying to get creative on what truly I would say our motto was listen to our dentist. What services do they need? What do they want? And then how do we build it kind of the back office infrastructure from there?
Michael: Was it an advantage or a disadvantage to have the legal training at the beginning in those early stages?
Justin: Not just saying this, because y’all are my first two bosses, let alone best bosses, but I think it did help because I mean, go back to you. You look in 2013. I mean, we were doing lobbying on the state board level cause at that point, DSOs were still frowned upon.
Justin: You know, everything was legal. I mean, compliance, everything had a compliance element to it. If you look at the average practice back then, no one knew what compliance was. No one had heard of starker anti-kickback [00:08:00] or any, I mean, again, it was just the wild, wild west and not intentional, but you have a dentist. Who’s the CEO, every department of Office. I mean, they just didn’t have the knowledge nor the time nor the, you know, guys like y’all to kick off questions, so it helped. But I mean, it’s funny to see today where now it is so professionalism and its professionalized there’s, everyone’s kind of evolved.
Brad: Yeah. So we were talking about DSOs, but let’s kind of dive a little bit deeper for our audience members. They’re used to going to see their family dentist every day, but there’s lots of different types of specialties out there. Tell us about the different specialties you see and work with, either from the DSO side or just in general.
Justin: Yeah, where I am at MB two, I mean, our model’s a little bit unique because we work with all specialties. I think there’s, you know, call it seven of them. Your general practitioner, which is the neighborhood dentist. You have an endodontist, which is as exciting [00:09:00] as root canals; you have a periodontist, prosthodontist, pediatric, oral surgery, and orthodontics. So you have some DSOs that focus on just one, there’s orthodontics, only DSOs. There’s maybe one or two oral surgery in pediatrics for us, I mean, ours is a, it’s a joint venture, but we have all those specialties. So, again, in that’s been kind of the, I would say the last two to three years has been a change about how do the specialties work together to give the best patient care, especially in COVID. It made you think, how do we reduce patient visits? Someone’s having, I mean, we all have kids; you’re going to the orthodontist, then you’re going to the general dentist’s office. And how do we shrink that to where it’s the easiest for the parents as well?
Brad: Yeah, that’s a good point. And you mentioned MB two. So maybe for our audience members, Michael, introduce just a little bit of background. We have Justin [00:10:00] on here. Not because he’s a friend, but because of your background, tell him, give some breath as to what he does. What is it your business does so they can understand your background a little bit better?
Justin: Yeah, so, MB two we’re based, based here locally in Carrollton, Texas. But, we have, I guess as of today, 475 practices across 38 states. Wow. And so we have about 800 dentists and about 6,000 employees, and all unique practices. So we are in rural Alaska to Manhattan, New York. I mean, it really does kind of span the spectrum. And our whole model is that every partnership in affiliated offices, we have that doctors have ownership and run their business. And our goal is how do we change as little as possible and just provide value. And everyone’s got different goals. Some people want more and more in this market; it’s HR help. How do we stay on top of that. I mean, ironically, the compliance in legal was no one cared about that three years ago and now we get a lot of questions on it. I think COVID [00:11:00] sped that up and we always say our motto is like, how do we get them to their personal and professional financial goals quicker and faster with less risk with us than without us. And it’s been, it’s been fast growth, but, I think today we’re like the fourth or fifth largest group in the country. And so, yeah, just trying to keep finding good doctors and provide value to them.
Michael: That’s fascinating. And I think just with my background, I think of a DSO as an entity that’s kind of providing efficiencies, and integration on the business side, but you mentioned something about, I don’t know if it’s clinical integration, but clinical efficiencies. Is that something y’all work on with having all these different practices join?
Justin: Absolutely. Yeah, I always say I’m like, we are not that smart. We just get to share wins and losses when you have 800 doctors and 475 practices. So like, even subspecialty, we have an orthodontic study group that on via our app, on our, on their phones, they’re [00:12:00] sharing literally live cases, case questions. What do you want? What would you do here? What do y’all think about that? And that is literally, I would say, dentistry, they always say, we always get the feedback and they’re on an island by themselves. I’m sure y’all hear that in every medical profession. And so that is such an underrated piece of this that it’s hard to measure, but, I mean, again, we’re sharing best clinical practices. We do two to three continuing Education events a month that are put on by our own doctors. Right. We have like, you know, if it’s the best, person in Invisalign, which we have, like they’re teaching the other members of the group, which buys into the whole culture piece. And, I think, people, when they’re aligned properly, they wanna share the clinical best practices and things that don’t work. You know, that’s what we see on just as much.
Michael: That’s fascinating. I kind of wanna sign up.
Brad: Yeah, me too.
Michael: We have one obstacle, I mean, we’re not dentists.
Brad: We are doctors though.
Michael: Yes. That’s true
Brad: Doctors in law.
Brad: So that can help at all.
Justin: Yeah. I tell a lot of our dentist all the time. I’m [00:13:00] a recovering lawyer, a Juris doctorate in a below average, one of that, but we’ll work on that.
Michael: I begged to differ, I’ve seen you practice. So, let’s move over a little bit off that and into just kind of some challenges that are facing the DSO, dental industry with the consolidation that you’re seeing.
Justin: Yeah, I think the consolidation, like I said, it has sped up since COVID. I think, you have the same problems kind of affecting, most businesses; you should see you. HR rising inflation, people forget, you know, if you go to whatever, a local restaurant, they can raise their prices, they just change the menu. We are in contracts with every provider, Blue Cross Aetna, Delta Dental. So we cannot raise pricing. And so for us, it’s, how do we get better pricing on our products? How do we leverage our own networks, to do more procedures in house that we [00:14:00] don’t do. Payer management strategy team, where it’s with data scientists and all they’re doing is analyzing rates. Should we drop a carrier, and go out of network or what’s the volume loss for that. And so that’s been something that is a huge challenge right now. And, like, I think with you having so many of these guys entering the space, and we always say, we want to make sure for the industry that there, as you know, everyone does it the right way, we integrate. The ability to integrate a practice into a DSO is probably the most overlooked part because we want to win the staff over, you know, we’re partnering with great practices and we don’t want to screw that up. And so it’s gaining trust, and that’s right now. I just think it’s just, turnovers, rampant across every industry. And so, our biggest it’s people business right now, like everything else, and if we treat our people, well, they provide good patient care.
Brad: And you said something I wanted to ask you a little bit further on. You were [00:15:00] talking about having people negotiate contracts and stuff. And from your market research that you were guys looking at, how different is it from a pay payer situation where you have a lot of situations where that community everyone’s in some dental plan, but other communities its cash based. So you’ll see. A big switch. Like, is it really state-driven or community-driven?
Justin: Yeah, I had no idea about this, but it’s completely community-driven. I mean, I didn’t realize there’s, I think we’re part of 145 blue cross dental plans. I thought it was just one, but like I always used the example. We have an office, you know, COAs in Amarillo, Texas, will that, you know, Delta Dental’s the largest carrier by far. The three biggest employers in the city are Delta dental. And so that’s very different. We have an office in Kenai, Alaska, which is basically a hundred percent out of network outs, and there’s, we accept one insurance and that’s the school districts. And so it is, it really is. It you have to look at every single office differently, which [00:16:00] has a scalability aspect. That’s tough. But that’s why the department’s growing because you, it’s not just one national co.
Brad: And do you see though, just in general, is it 50/50 when it comes from cash in contracts or is it so all low place nationally, you can’t even figure out what those numbers look like.
Justin: Yeah. I mean, I think they do a good job of not giving us great data to compare; it’s like apples to oranges. And so, I mean, yeah, like you’ll find a rural town that has a 35% better rate than a town 45 minutes away makes no sense. That’s the hard part of how we fight for the doctors and try to just use data to show that with our compliance team, we have all this we were able to show that the overall lifespan of care is for the insurance company, a better perspective us than without us. Cause we can service them. The whole town essentially.
Brad: Right, that makes sense. Well, now that we’ve kind of walked a little bit further into the DSOs, [00:17:00] from a business perspective, what is the biggest business challenge that a DSO faces?
Justin: Yeah, I think right now you’re seeing scalability. I remember when working with the Allman a lot of times it was easy at one office and two, but growing in size. I mean, you have to put up infrastructure; you have to spend money. If anything, you’d probably take us a couple of steps back. And so we added 108 offices last year. Goodness. We had years where we did none because we were having to build out the revenue cycle team or build out the HR team, or we grew, and if you’re not careful, you grow too fast.
Justin: But it’s constantly gauging that. How do you build enough infrastructure for growth, but still be fiscally responsible, and not spend too much. And we want to be around 10 years from now, not just, you know, quick flips. So I think scalability’s right now, the toughest, just with all the competition that’s out there. [00:18:00]
Michael: And you mentioned earlier, just the, the. People problem or people challenge. There’s not enough employees out there. I would imagine that that really comes out when you’re trying to scale. Yeah. I mean, you, you, if you have like, you know, we measure turnover in every department, every office, I mean, if you’re turning over 15, 20% of your workforce, I mean, that’s hard enough as it is, but when you’re growing 20% it just compounds that problem you have to. And so we try to be scrappy about it and its like, how do we widen the pool and increase the pool of candidates, but also you never want to sacrifice quality and it’s tough. That’s something that we have not cracked yet. And, and we are just having to right now throw, kind of just throw manpower at it. And our HR team has doubled, I think, since COVID and we’re still hiring, so, wow.
Brad: And when it comes to one year, you’ll kind of hit the pause button, how hard or was that on your own investors and people who are, I guess, the people trying to go out and find practice [00:19:00] for Kind of reign them in for a year. Was that a difficult thing or was everyone kind of rowing with y’all?
Justin: No. Yeah. I think that at that point, we were just privately held by a bunch of dentists. I think that enabled us to do what’s right for the business. You mean, you’re right. If you have a private equity investor, a family office, they’re looking at one thing, and that’s the rate of return. Right. And so if you’re sitting out a year, it’s a tougher conversation, which we try to be very, very, very picky about who we partner with because of that reason. Right. I think you, again, I think most are smart enough to realize like, okay, you take a step back, but you’re going to take two forward. Whatever the old saying is. But no, I mean, that, again, we had the luxury of we’re still led by, you know, my boss, our CEO and founders of the dentist. And we were all our money was. Just a bunch of dentists. And so I think it’s much easier. They understand they were feeling it firsthand, that we needed the infrastructure and press pause.
Michael: That’s good. Well, let’s kind of shift again. I would love to hear about the biggest healthcare compliance challenges [00:20:00] you see, kind of in the DSO world.
Justin: Yeah, I think this is again, it’s sped up. I’m lucky enough, my brother-in-law’s a private practitioner, he’s an orthodontist. And so he and I get both perspectives of a massive company hitting him, and compliance was a word that no one knew. Right. But now it’s like we have everything from we have payer audits, which never had 10 years ago. And not just from government subsidy, Medicaid, Medicare, but you know, you have blue cross when we get an average of about three to four a week that you’re having to pull charts, provide narrative responses, go through, find old x-rays you, you name it. I mean, be very clear, an insurance company, you know, their job is to essentially not paying you on certain claims and they want to ensure good quality of care is being done, which we of course respect. But, but it’s a tough thing. You get that as a private practitioner, when do they have the time or the expertise to do that. And I think we’re seeing that, [00:21:00] dental board that’s just increasing, you know, most states, that’s not an area that’s been cut. And so you’re seeing more and more dental board complaints and just more complexities with credentialing of getting, getting licensure properly. The credentialing component with all these insurance carriers used to take 20, 25 days. Now you’re up to 90 days.
Justin: You know, because they’re understaffed. I always say, even as an attorney. Taken for granted sometimes, is HIPAA. , you know, it’s like, okay, everyone knows what it is, but you know, it’s a real thing you, I’ll give a real example, we had an office get broken into and people were stealing. You know, they were looking for things like money, and scripts basically to write, but they took a computer. Well, four or five years ago we had poor control at that time and didn’t have everything properly encrypted. And we know it was lucky [00:22:00] we had cyber insurance; we were called upon some great experts, but, you know, it could have been up to a million dollars. It would’ve crippled one office dental group. And so we have three full-on people. All they do is do cyber work. And then, you know, OSHA.
Brad: Do you sometimes walk by the office and laugh at ’em and point at ’em and keep walking?
Justin: No, I try never to walk by them so they don’t get on me for whatever I’m violating, but I mean, again, OSHA COVID I never even heard of the word OSHA, dental op you know, we had three or four OSHA reviews. I think, you have marketing examples of, can you do this? Which goes back to this, can you say this in an advertisement? Can you have a referral relationship? You know, I think what y’all do day to day, but the structuring of transactions, every state you have in the dental world, like North Carolina is tremendously more complex than Texas, for example. And I think that kind of the newest phase of what we’re seeing in the legal side is kind of the CRA I guess the combination of dental and other medical [00:23:00] specialties, like Aspen dental, which is the second largest group in the country, they are now, they’ve now acquired a veterinary platform, a med spa platform and an urgent care platform under one umbrella and so that is like the next 10 years of how we incorporate kind of the whole and other healthcare verticals.
Brad: So that you can get your dog Botox. Is that what I’m hearing?
Michael: I think you’re jumping to some conclusions, but I like where you’re going. I like that I think that’s an opportunity.
Brad: Veterinarian med spa and getting their teeth cleaned. Yeah, I like it. I mean, I see big money here.
Michael: Yeah. I have to, I’ll observe too. I mean, even on our shows and talking to others and the things that we’re talking about, we see this kind of idea of integrated healthcare. Showing up where people are trying to figure out how people with different licenses can work together. And I can imagine that would be a challenge in your [00:24:00] world, but not one that I’d really thought about until you just said that.
Brad: Especially dogs.
Michael: Yes, Brad.
Justin: Have you ever taken a dog to get their teeth cleaned? It’s about four times what it costs for a human to get their teeth cleaned.
Michael: Yes, I have. It’s complicated.
Justin: But no, I do think that is kind of the future. It’s integrated its how do we use patient data together? Like one health visit kind of thing. And you know, I mean, if you look at oral health and how it affects you, Comorbidity like preexisting conditions. There’s a lot of data out there that I think will just get there at some point.
Michael: That’s awesome. Believe it or not, Justin we already have reached our time. So, what we’ll do next is we’ll say bye and go into a commercial. Then Brad, we’re going to have to come up with something legal to say on the other end or just make fun of each other.
Michael: Either way, but Justin it was awesome having you. Thank you for joining.
Justin: No, thank y’all for having me!
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Brad: Welcome back to Legal 123s with ByrdAdatto. I’m your host, Brad Adatto. I’m still here with my co-host, Michael Byrd. Now, Michael, this season, our theme is especially spotlight. We just had our longtime friend and colleague Justin Puckett join us. And there’s so many great things that he said, especially the fact that he liked me better than you, but the focus that he brings into this market from the DSO, the dental support organization, it was great hearing his thoughts. I mean, this is a guy who’s [00:26:00] been in it, obviously since the beginning of time, he even said how he was one of the first people in that area. And it was really the growth side of it. But for our audience members that want to understand better why they need to have a DSO. He laid out a lot of different pieces as reasons for that really being in their back office, similar to an MSO, but maybe you can help sign a light on other aspects of it, which as to w what are reasons for having DSOs?
Michael: Yeah, we don’t even talk about it anymore, but the fundamental why of having a DSO is because you have a non-dentist wanting to be a part of a business that is practicing dentistry.
Michael: And the laws are very similar in many ways to medicine, in the sense that many states have a corporate practice of dentistry law. The states vary and they regulate who can own a business that’s PR practicing dentistry, and sometimes they even go further than that, who can [00:27:00] operate a business that’s practicing dentistry. So the DSO market came about because of this, that very fact that you’re trying to navigate the corporate practice of dentistry. You and I talk about this often, is that the dentistry kind of industry is a great preview for the medical industry because they’re about 10 years ahead of medical. You heard Justin talk about the low number of members in the DSO, you know, trade association. Well, there’s not really even MSO trade associations yet. Even as an example, in Texas, there’s now legislation regulating DSOs and maybe something we’ll see in the future on the medical side. Then, of course, the corporate, you know, private [00:28:00] equity roll. Stuff that that Justin talked about, that is a huge player in DSOs and again a good preview for what we’re starting to see on the medical side of things.
Brad: Yeah. Especially hearing him talk about a lot of these dentists on their own little island. Audience members know when we talk a lot about these small practices on the medical side, it’s the same concept as if you’re out there by yourself. So, you can just go join the local hospital because you can’t figure out how to do it by yourself anymore. Or you join a giant mega group. Well, that’s this same concept of this DSO, bringing it along saying, well, you can still basically run your practice in the sense that you get. You get to be a great dentist, but let us help you with all the other compliance aspects. And as Justin was saying, it gets more and more complicated. You actually have to learn more about that, and that’s what the great aspect of being a part of a program like that is.
Michael: Yeah. And I would just say too, that it’s it. We can make these [00:29:00] analogies to make everyone kind of see the patterns of similarities. At the same time, it’s really important to understand that there are nuances, like the corporate practice of dentistry is different than the corporate practice of medicine. So yes, there is when we’re doing dental deals, you know, again, we’re focusing on the state. Yeah. What state are they in? What, how do you navigate that when you’re setting up your DSO? Or if you’re doing an M and a deal in dentistry, there are nuances that are different. And there are some things like HIPAA that have a lot of similarities regardless of what type of license you’re dealing with. But it’s easy to draw these analogies to kind of show the similarities of these different licenses out there, but don’t want to lose sight of the fact that they’re regulated differently and there are nuances.
Brad: Yeah. It’s like a lot of things. Just because it seems like its [00:30:00] the same, it’s not, so just because we don’t charge our guests any money doesn’t mean that we’re not as good as those other podcasts.
Michael: True, yes. Although, I think we should start charging them
Brad: yeah, I agree too.
Michael: Or I’ll start charging you.
Brad: Yeah. I don’t like that idea. Riley, scratch that. Don’t let the bee on there. Michael that is unfortunately the end of season nine on specialty spotlight. Do not panic, Michael. Sit down, sit down. Don’t run!
Brad: Season 10 is just around corner, so listeners out there… Guess what? On October 5th, 2022, you get to learn all about what we’re releasing next.
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