

26. A buyer’s and seller’s guide to navigating practice transition day
With Dr. Lee Maddox
Buying or selling a healthcare practice is usually one of the biggest financial decisions of a doctor’s life.
It can be accompanied by stress, uncertainty, and even conflict.
Since it's something most people do only once (maybe twice), the laws and best practices that govern practice transition can be unfamiliar or confusing.
Meet our guest
Dr. Maddox practiced endodontics and maintained two offices in Orange County, California, for five years. During this time, his practice increased production by an incredible 700%.
In his post-provider life, he's been providing legal services to dentists since 2001, helping thousands of doctors with their transition needs and general ledger services. He's been in the dental transition business as a practice broker from 2010-2018 and practices law full-time to support dentists, veterinarians, and other medical professionals.
In this episode
- The importance of fostering appropriate communication between buyer and seller
- How to pair the right buyer with the right seller
- The special nuances of a practice transition between owner and associate
- What to expect on transition day
- How to prepare practice staff for an ownership transition
Episode transcript


Today we are here at the California Dental Association Convention in Anaheim, California, and I'm thrilled to be joined by Dr. Lee Maddox. Dr. Maddox practiced endodontics and maintained two offices in Orange County for five years. During this time, his practice increased production by an incredible 700%. In his post-provider life, he's been providing legal services to dentists for over 22 years, helping thousands of doctors with their transition needs as well as general ledger services. He's been in the dental transition business as a practice broker from 2010 to 2018 and practices law full-time to support dentists, veterinarians, and other medical professionals. Dr. Maddox, pleasure to have you here today. Thanks for joining us.







So I don't have a problem with buyer and sellers communicating, but I'd like them to talk about dental issues, not legal issues. And if a legal issue comes up, I ask them to put the pause button on, listen, and then let's revisit that later after they've had a thorough understanding of how that could impact them not only in the short term on liability level, but on the long-term liability level. So my position is if you want to talk about clinical, you want to talk about scheduling patients, you want to talk about staffing issues, I'm fine with that. If you want to talk about issues that could affect your long-term liability or could ultimately cost you money either immediately by purchase price adjustments or allocations on purchase price, but it could cost you money later on liability issues if you don't fully comprehend the complexity of the situation.


But really, the whole concept of transition from the buyer and the seller side is really predetermining what they're looking for. And if they communicate that effectively to the seller broker, then the seller broker should be the one that's filtering through the buyer group to bring just what the seller is looking for in a non-discriminatory manner, of course. But bringing somebody in who has a philosophical match somewhat consistent, and with the post-closing transition strategy somewhat consistent with the seller's expectation. And so the whole transition process from a brokering point of view should be managing the expectation of the seller. And in order to do that, the seller has to communicate effectively as to what they're looking for. And on the flip side, same thing with the buyer, the buyer's got to communicate what they're looking for and that can help manage the expectations better post-closing.


If philosophically you're a person that's okay selling to a DSO/corporate buyer, then that's great. But there are many doctors out there that are not on that page, that they're not mentally on board with the idea of selling to a DSO because they have preconceived perceptions, whether they're right or wrong, as to what that would mean. Some of those perceptions may be how they think their patients are being treated or how their staff is being treated, and that may be a naivete, but they may have this preconceived idea and so philosophically, they may be against having a DSO buyer, and they like the idea of having a peer-to-peer relationship so they'll go for a non-corporate buyer. It'll make them feel better, maybe potentially, about how the patients and staff will be treated. And some doctors are looking for a legacy practice that's going to look substantially similar as the way they left it, and some may feel like that's going to happen.
The reality is once anybody buys the practice, the practice changes, and the more money they pay, the more likely it is the changes are going to happen and they're going to happen quickly. So it is just kind of a nuancey thing, and they have to just decide philosophically, am I onboard with a corporate structure or am I onboard with peer-to-peer type of transactions? So the DSO buyers are very different than a one-off buyer, and it's a much different experience from the seller side, of course.
But really, the whole concept of transition from the buyer and the seller side is really predetermining what they're looking for. And if they communicate that effectively to the seller broker, then the seller broker should be the one that's filtering through the buyer group to bring just what the seller is looking for in a non-discriminatory manner, of course. But bringing somebody in who has a philosophical match somewhat consistent, and with the post-closing transition strategy somewhat consistent with the seller's expectation. And so the whole transition process from a brokering point of view should be managing the expectation of the seller. And in order to do that, the seller has to communicate effectively as to what they're looking for. And on the flip side, same thing with the buyer, the buyer's got to communicate what they're looking for and that can help manage the expectations better post-closing.


There's a potential that the volume of the practice will go up, but then the question is how do we quantify the volume that went up and what's accounting for that increase in volume? Is it because the associate brought in business? Is it because the associates speed in doing the dentistry? Or is it because the associate freed up the senior doctor so the senior doctor could do different and more complex and more expensive procedures? So what we get ultimately downstream is that the buyer and seller disagree as to what the purchase price should be and if they disagree on what the purchase price should be, then the buyer's going to walk because they think they're paying too much for a practice that they help grow.
The associate buyer can be the perfect choice, there can be a mentoring relationship, they can have everything work out, and we can have just fantastic transitions if everybody will follow the guidelines that are put in place. But there's a lot of intervening forces out there, a lot of things that happen societally that can change the personalities and the attitudes of how people approach their situation. And that can be from a family life matter to on a social/financial level, economic realities of the world. But it's really interesting that the associate ownership model I think is really a good way to go with certain specialty practices like perio and endo, we see it a lot with oral surgery. We do see it in general dental practices as well, but it's a good way to transition a practice and for somebody on a seller side who wants to be in a mentoring relationship with a younger person and provide them the opportunity that maybe they had, it's a good way to go.


So if you put together a memorandum of understanding, it's low stress. Everybody can think it through, cogitate on it and make an informed decision. And then if they're willing to move forward off of that, we can put a document in front of them that they sign. It's a good strategy. I think it's important for the seller to talk to their attorney first, it's very difficult for the buyer to forecast what the seller is going to agree to. So if the seller will communicate with an attorney, lay out a really clear pathway on what they're looking for and then the buyer buys into it, then I think the transition works really well.


What's interesting about this, it's really a two-part model. There are people that are going to help you pre-closing and there may or may not be people helping you post-closing. So pre-closing you may have an attorney, you may have a consultant, you have a lender, you have a broker, and some or all of those may go away right on the closing date. So the attorney's relationship has been completed, the documents are signed, the attorney's not going to be there on the transition day, the consultant may not be there on the day, the lender's not going to be there on the day, the wire's going to go out and the broker is going to be gone. And then post-closing, the only two people that are left are the buyer and seller who have almost not communicated, right?


And then if we get a consultant on board early, and then if we can keep the consultant with the doctor working six months after, then we have a really nice transition strategy because what we'd like to see is the buyer not to make material changes for six months to a year after the transaction. Because when a buyer's buying a dental practice or buying goodwill, the definition of goodwill is the expectation of future business, I call it the momentum of the practice.
So how do we maintain the momentum of the practice? Well, you maintain the momentum of the practice. You don't change the staff, you don't change the hours, you don't change the billing mechanisms. But all those things have to be discussed upfront with the consultant because some of those things may require changing. There may be some serious problems. So we can't just make a wholesale decision that we're not going to do those, but then we got to evaluate the consequences of making those changes. If you make a change that isn't well-thought-out, then you may lose staff or patients and that can cause a serious reduction in the productivity of the practice, and that could take years to recover.
So having, I think, a practice consultant involved pre-closing and having a practice consultant post-closing is really important. So I said there's two groups of people. After the deal closes, you're not working with your dental lawyer unless there's problems. You're not working with the broker because the broker has done the job, he made the match, he completed the transaction, and they're gone. And you're not working with the lender. So now it's just you and the staff and the doctors and the staff could be unhappy because they weren't told about the sale. And then now we got to go in and try to operate the practice day one, and if we don't have a consultant to help communicate with the staff, and that can make a difference.
But I want to back up and say that really critically, buyers have to have a plan and they have to articulate the plan in a meaningful way that the staff can see the future and buy into it. So if the buyer buys the practice and has no plan and comes in with an attitude of, "I'm just going to do clinical dentistry and I'm not going to focus on the business side of it," then chaos ensues. And naively, that's what I did when I bought my practice. I thought the best thing I could do when I bought the practice was just focus on the dentistry and everything else would work out. And after a year, I realized I didn't understand anything about the business and when all the staff walked out the door, I had no understanding of how to operate a business.
So it's a very difficult process for a young buyer to come into this situation because they're at the age where they're either dating or they're married or they're having children or they have young children and they've just gone through this incredible 60, 90 day process of working with multiple parties, like a hub and a wheel, there's all these things going on in financing and insurance and due diligence, and all this stuff is going on, and then the deal closes and it's not relaxing. All of a sudden you got to work harder and you got to be a business person and you got to be a clinical provider, and you got to make the patients feel comfortable, but you also have to manage the practice. So there's some difficulty on that day.
The nice thing is we're dealing with some really bright people. Most of these dentists coming out of school have been in the top five or 10% of every class they've ever been in, they're very intentional people, they're very goal-oriented people, they're very competent people, and they come out of school well-trained. So the dentistry part, they have most of it in place. Diagnosis, treatment planning, delivering the services, selling the stuff is the one part they don't do a lot of, but they have the skills they need to do the clinical part of it. And then the management part is something that they have to be, again, intentional about to make sure that they're knowing what the front office is doing and how they're doing and how the back offices are operating.
And that's where the seller can come in and offer some assistance. So most of the time post-closing, the buyers want the seller to stay. It's like a warm blanket, it makes them feel good. And they will typically say, "I'd like to have the seller there half a day a week." You say, "Half a day a week and do what?" "Help me meet the patients." "Well, that's only five patients. What about the rest of the week?" So normally I'll tell sellers not to stay unless they're doing dentistry because if the seller's there, then the patients are going to want the sellers to work on them, the staff is going to go to the seller and the seller's going to be bored because they're not doing anything, the buyer's going to be busy so it can be an uncomfortable transition.

I'm Corey Brown, and this Provide's The Path to Owning, a podcast. We're back with Dr. Lee Maddox to dive into the details of the buyer side of the transition process. Dr. Maddox, what's the best way for a buyer to understand the mindset of the seller and approach him the most successfully, would you say?

If they then get an opportunity to talk to the seller and ask them how they manage post-treatment problems, patient management problems, staffing problems, then they'll get a better understanding of the personality of the doctor and the doctor's way to manage those problems. And if the buyer comes in and has a consistent approach, the transition will be smoother. If the buyer comes in with a dramatically opposite approach, then we're going to find that there's going to be differences of opinion.
So again, this is a separation between private party deals, and this is a separation between a broker-managed transaction. And I manage broker deals in seven states with multiple brokers, and we maybe kept the buyers and sellers apart a little more than we should have. But when I sold my practice, I wanted to know everything about my buyer, not only what kind of a person he was in a normal environment, I wanted to know what kind of person he was in a competitive environment. So I took the extra steps of playing tennis with him and going golfing or playing bowling with him to see if he was going to cheat, call balls out and I wanted to know what kind of person he was under duress, under stress, how competitive.
But that doesn't happen, that's not the reality of practice transitions. And buyers and sellers typically don't have that opportunity. The process is so stressful that there's this moment in time where a letter of intent is signed and then there's a little drag in the relationship, nothing happens for a while. And during that time, the buyer's trying to get a loan approval. And then once the buyer gets loan approval, we've eaten up a lot of the transition time at that point and so we have one or two weeks left or three weeks left to do the entire transaction, to get the purchase and sell agreement done, to get the lease done, they get the insurances in place, they get the disability insurance in place, and the buyer is still trying to work as an associate, the seller's still trying to run the practice. They have no time to communicate.




In contrast to that, in a private practice deal, most of the time the staff doesn't find out to the day of. And this is one of those things from a lawyer point of view, I don't have the right answer. I have answers, I don't have the right answers. I've had sellers that have introduced the idea that they're selling their practice to the staff and the staff has all quit, and then they got to hire a new staff. And that's not good for the buyer, and that's not good for the seller.
So if the seller has an amazing relationship and a high level of communication with their staff where they trust each other implicitly, then the seller can tell the staff and they will be pooling for him and happier for him or her when they go through the transaction and it can be then a nice thing to have the buyer introduce the staff pre-closing. If he doesn't have that high level of trust, then the seller is going to be advised not to introduce the staff until the closing date. Now, I'm not opposed to having the staff meet the buyer on a peer-to-peer sale transaction if all the documents are signed. We have the purchase and sale agreement signed, we have the office lease signed, we have some kind of a post-closing transition associate agreement signed, and I feel like the buyer would be in breach if they walked from the deal. We will then allow the buyer to meet the staff and then see how that experience is going to happen.
But post-COVID, everything has really changed. It's very difficult with the staffing side of things now, it seems like maintaining staff is harder, getting good staff is harder. And because of that, the staff can jump ship and go get paid more at another office. So if you tell the staff early, they have a friend who works in another office and they've been looking for somebody for six months and you're making 20 bucks an hour, they're going to give you 25 bucks an hour, the person you've been loyal to for 10 years is selling the practice, there's no loyalty to the next person and they'll bounce out. Most of the time, the staff doesn't find out until that day, there's tears, they're being terminated, they're being rehired and then the buyer has to go in and sell the vision.
And that's really the plan. What are you going to do that makes me want to stay here? Why do we want to work for you? And that may be introducing new technologies, that may be introducing new methodologies of how we do things, that may be making the practice busier. But all of those things can be scary, and that may cause the staff to change or it may make them excited about the opportunity to be in a practice that's going to grow and be part of that new dental team that's growing. You don't know what's going to happen because you've never met the staff.
So it's really interesting. I've had some staff members call me up and say that it was horrible what we did, why didn't we let sellers tell them sooner? And it's really hard. If the seller tells the staff sooner, they're asking every day, "Is the deal going through? Is the deal going through? Is the deal going through? What am I going to get paid? What about my vacation?" And these are all very important questions, but we don't have that answer until the buyer takes over. And once the buyer spends half a million dollars or a million dollars, the buyer's going to do it their way. And the seller really has no say. And so post-closing, all those issues are managed by the buyer's side so the seller doesn't have any say on it. It's a very tenuous situation.
Thankfully, most of the time it works out. Some of the staff members for financial reasons can't leave, some staff members are excited about the change, some staff members have been expecting to change. It's unusual for both the patients and the staff members to be asking aging dentists, "When are you going to retire?" So there's this level of expectation and they're happy for the seller and they're looking forward to a new opportunity with a younger person and taking a practice maybe to its maximum potential.


Now, I once lectured in a room of a couple hundred people, and before I made this comment, I asked how many people in the room were consultants and there must have been seven or eight consultants. And I said, "I'm going to say something right now that's going to offend all the consultants," and I said, "If you buy a practice and the seller's not collecting payment that day, and then you change the practice to collect the payment that day, you may irreparably harm the patients." All the consultants are going to say, "What do you mean? You have to get payments that day." And they're right, they should get payments that day but that shock to the patient population is something that they have to be prepared for if that shock can cause them to leave.
So I think that there has to be, like I said, a good thorough understanding of the practice before you close the practice. We'll give you this plan so you're not shotgunning it. So the transaction closes, you are articulating with your team, "The deal was closed, this is our plan. We need to start collecting and we need to stop waiving co-payments, we need to get off Delta. We need to do no Medi-Cal, or we need to do Medi-Cal," but articulate the plan and lay out a strategy as to how you're going to get from A to Z so that everybody's comfortable with that. And some people can take change better than others. And the ones that can't shake it will jump ship and the ones that are excited about the change because they know the flaws in the practice will be excited to stay on and move forward with the practice.





Provide, Inc. is a wholly owned subsidiary of Fifth Third Bank, National Association. All opinions expressed by the participant are solely their current opinions and do not reflect the opinions of Provide, its affiliates, or Fifth Third Bank. The participant’s opinions are based on information they consider reliable, but neither Provide, its affiliates nor Fifth Third Bank warrant its completeness or accuracy and should not be relied upon as such. This content is for informational purposes and does not constitute the rendering of legal, accounting, tax, or investment advice, or other professional services by Provide or any of its affiliates. Please consult with appropriate professionals related to your individual circumstances. All lending is subject to review and approval.
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