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Hello everyone. This
is Erica Spicer Mason,

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writer and editor with
Becker's Healthcare.

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Thank you so much for tuning into the
Becker's Healthcare podcast series.

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Today I'm happy to be
joined by Duff Bourassa,

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the managing director of D S O
M S O growth at E 78 Partners

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who will discuss month-end close for DSOs,

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how to leverage key KPIs to drive value,

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as well as the importance of
financial planning and analysis. Duff,

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thank you so much for
being here with us today.

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Yes, thanks for having me.
Excited to be a part of this. Oh.

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We're thrilled to learn from you
here. But before we get started,

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I was wondering if you could just give
our listeners a little bit of context,

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maybe share a little bit about your
professional background as well as E 78

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partners.

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Absolutely. You know, I, I kind of came
to dental, uh, through a unique route.

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So I was a insurance, uh,
owner. I, uh, managed a,

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an insurance agency and, and
just had a lot of dental clients.

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And so I was really kind of
fascinated, uh, by that, uh,

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by the industry as a whole. And
so started to work with, uh,

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private equity firms that were
buying, uh, other dental practices,

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and they allowed me to build out the risk
management strategy for the insurance

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program for these dentist groups. And
so, as I got to learn and meet these,

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these dentists, I started to see that, uh,

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most of the time when they were partnering
with the D S O, they didn't have, uh,

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any representation. And, uh, you know,

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I just thought that that was a good
opportunity for me. And so I became a,

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a dental broker, started doing sell side
advisory work with these dentists, and,

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uh, really just fell in love
with the industry and saw how,

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how profitable it was and, and just
how it was just a good opportunity for,

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for both the DSOs and for, for
dentists and at a whole. So that,

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that kind of led me, uh, to research
DSOs as, as you're a sell side advisor,

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you wanna make sure you provide the best
partner, uh, for the dentist. And so I,

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I spent, uh, years researching, uh,

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every D S O I could find to
learn how they partnered,

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what they were looking for,
uh, and ultimately, you know,

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wanted to feel confident
that I was providing, you
know, the right service, uh,

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to my clients. And so along the way, uh,

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I ran across a group called E 78 partners,

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and really was intrigued by what they
were doing and how they were helping, uh,

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the industry as a whole
grow. And so that, uh,

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that kind of led me to E 78 and into
the position I'm at, uh, today. And so,

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just a quick blurb about
E 78, you know, uh,

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we are a consulting and advisory firm. Uh,

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we provide accounting and technology
services to middle market companies.

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Our FI founders actually came from
private equity. So they were, uh,

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acquire acquiring founder-led companies,

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and they found that most of the companies
they were buying really lacked the

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true accounting and finance function,

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and they rarely were investing in
technology. And so as they started E 78,

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the, they really wanted to bring sort
of the sophistication of a fortune,

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fortune 500 level accounting, finance,

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and technology team down
to the middle markets, uh,

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so that they can better drive those
smaller companies. And so, you know,

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that makes a lot of sense
from a dentist standpoint,

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because dentists go to school to
learn how to work in the mouth.

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They don't really know how to run a
business from a finance standpoint.

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And so our goal is to really educate
them and, and give them those resources.

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Oh, thanks so much duff for that overview.
That's really helpful. And I mean,

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it sounds like you must know this industry
inside and out coming from, you know,

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having your own insurance agency with
dental clients to where you are now with E

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78. Um, sounds like you have,

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I'm sure you have a lot of great insights
to give us here as we're talking about

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finances in general. So to get us started,

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just especially based on all
experience you have in the industry,

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I'm wondering if you can share with us
your high level assessment of how the

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business of dentistry has
really evolved recently,

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especially considering what we're
seeing with widespread consolidation and

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changes in patient experiences.

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How has that really changed the
business operations for DSOs?

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Sure. Yeah. So I,

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I tend to look at the
business of dentistry in sort
of four distinct buckets.

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So we've got operations, we've got
finance, we've got HR and marketing.

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And so from an operation
standpoint, you know,

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technology has been the biggest
driving factor, uh, of change, uh,

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in how dentistry works today.
Patients now bed days, they,

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they want all of their interactions
via their phone. You know,

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they don't wanna talk to anybody anymore.

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So they wanna be able to set
an appointment on their phone,

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they want to fill out all the forms,
they wanna see their e o B on the phone,

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they wanna be able to pay by their phone.

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So all that intake has drastically
changed. There's, you know,

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you don't just go and show up in an office
and schedule an appointment anymore.

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It's all done remotely. And so as,
as you move to the chair, you know,

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there's been this sort of shift to
what we call emotional dentistry. So,

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you know, we can now create a
virtual smile on the screen,

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and I can physically see what my smile
would look like if my teeth were wider,

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uh, if I got a gap fixed, or if
I had a crooked tooth, you know,

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I can physically see what's it
gonna look like if they fix it. Um,

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and so as I'm sitting in the chair, that
greatly increases the case acceptance,

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right?

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I'm much more likely to do that if I
can physic physically see the effects of

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that. And so that, that technology,
um, has drastically changed,

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uh, a lot for, for the groups
that are, that are implemented.

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And the same thing goes with, with laser
dentistry. You know, we can now do, uh,

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some cavity and gum repairs with
lasers, so no more drilling, uh,

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so less, less pain, um, you know,
you don't hear the drill anymore.

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So those are all positive things that, uh,

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leads just a better patient experience.

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And those are the things that we are
seeing that really help groups grow.

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So from an operation standpoint, I would
say technology is really the main, uh,

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change there. On the
finance side, you know,

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historically we had local
servers, paper charts,

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and if you wanted to get any work done,
you had to physically go to the office.

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Well, now everything's moved to the cloud,

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so I can literally manage
10 stores from one location,

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or I can do it all from home. Um, so
being able to track my revenue trends,

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my supply variances, whatever
KPIs are important to my group,

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I can do that all now remotely. And
it's all automated. And so really the,

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the biggest evolution there is just
that ability to take things from a local

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machine and put it up in the cloud.
Everything's so much more scalable, uh,

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and I can do so much more from, from home
or from, uh, from wherever I want to.

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So from a finance standpoint, that's
a huge changer. And then in hr,

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really, uh, turnover has been the
biggest change, right? So post covid,

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they say 10% of hygiene
is just never came back.

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And so how do you keep the staff that
you have and how do you not have to

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break the bank to get quality people?

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And so really groups that can
create that culture, uh, and,

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and find ways to touch, touch in with
their people and keep them motivated,

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keep them involved in the, in the office,
uh, those are the groups that are,

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that are doing well because, uh, I
don't see that changing anytime soon.

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You know, the hygiene, uh, schools
keep saying that enrollment's up,

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which is great. But, uh, we,

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we still don't see a huge influx and
in every group I talk to struggles to,

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to find staff. So really just the ability
to keep people on an HR standpoint,

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uh, is, was one of the biggest change.
And then last piece is marketing.

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Really main evolution here is just
how everything's gone digital. So,

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you know, historically it
was print media and mailers,

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and then we kind of
transitioned into SS e o and,

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and trying to be found easily online.

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And now it's much more proactive.

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So there's groups out there that are
scraping all the data and all the searches

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we do on our computers and on our phones,

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and they can literally target people
with our ads. And so if I, uh,

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if I see someone in my neighborhood
that's searched teeth whitening, well,

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I can put an ad on their Facebook feed
for I'm offering free whitening with,

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with the cleaning. And those,
those companies out there
exist, and it's amazing,

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and you've probably seen
it in your own life.

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You talk about something or you search
something, and next thing you know,

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it's in your Facebook feed. So that's a
huge switch from a marketing standpoint.

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You've gotta be proactive, uh, in
that, that phase. So, you know,

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those are the trends we're
really seeing. Um, you know,

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dentistry is still as popular
and as profitable as ever,
but it is becoming, uh,

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increasingly competitive,
uh, across those phases.

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Absolutely. And thanks Duff for
the way that you outlined that.

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I really appreciated it. And, you know,

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it sounds like with these shifts
and changes in technology,

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digital tools, and then, you know,

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you mentioned from a finance perspective
really managing a lot of those

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processes on the cloud at the same time,

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<laugh> managing turnover
from an HR standpoint,

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it's a really dynamic environment. So it
seems like in this kind of environment,

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it would be important for DSOs to really
ace the fundamentals when it comes to

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financial operations.

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So can you share some common operational
challenges that tend to hinder

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dental organizations'
financial performance,

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and what can organizations do
here to overcome those challenges?

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Absolutely. So, you know,

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integration is what really comes to
mind when I think about the operational

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challenges. You know, most DSOs
are growing via acquisition.

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And so when they do that, they're,
you know, essentially, um,

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everyone's fighting for all these good
practices. And so you've gotta have, uh,

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you gotta have an integration plan as
to how we're gonna bring, uh, these,

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these practices on. And,
you know, when DSOs, they,

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they wanna promise the
world, they, they offer,

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but when they talk to doctors or, Hey,

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we're gonna give you as
much autonomy as possible.

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And from a clinical standpoint,
that makes absolute sense.

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But from an operational
standpoint, you, you've got to,

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you've gotta take some of that autonomy
away because we need everyone to operate

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in a similar fashion when it
comes to the back office. Uh,

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because the reality is, is most dentists
are, are poor at budgeting and finance.

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You know, they don't do a
13 week cashflow report.

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They look at their p and l statements
at the end of the year when they,

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their tax, their C P A files their taxes.

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So they really lack the key metrics
that are gonna allow them to grow.

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They don't have access to it.

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So the quicker we can get those
offices onboard with what our

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operating processes are, right,
how we onboard new patients,

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what data we enter into the p m
s tool, how we verify insurance,

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all of those things that we do
on the front end really have a,

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a ripple effect downstream into how we
build out our reports and how we measure

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the performance of our offices offices.

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So the quicker we can integrate
these acquisitions into the fold, uh,

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the better we're gonna
see a, a return there.

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And so the first thing I think of is
just from an operations standpoint,

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is just integration.

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Like we've gotta have a solid
process into how we integrate those,

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those offices. And then, you know,
another common challenge right now is,

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is the revenue cycle management. Uh,
R C M is, is is a real hot topic in,

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in the D S O world, because most groups
struggle to do it well. Um, you know,

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we see a lot of companies
that use Excel spreadsheets.

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They'll download data out of their p
m s tool, they'll put 'em into Excel,

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they make a, a lot of manual manipulation,

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and then they upload it into
their accounting system.

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It is a very manually intensive process.
It's, it's horribly inefficient,

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and it, it adds to how long it
takes for us to collect money.

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And so when you're, when you think
about that process, and now we're also,

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we're trying to grow and acquire. So
we go out, we get five more offices,

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so now we've got five more offices
sending us an Excel spreadsheet and just

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trying to manage that. It,
it's not, it's not, uh,

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it's not feasible for most groups.

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And so it's important to use
technology where you can,

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but it's also important to have a a an R
C M process that you can utilize across

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all locations, because if one
office does it differently,

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it throws off the entire
report for everybody.

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So really understanding R C M and
having a process in place, that's a,

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a huge hurdle, uh, and something that
we see a lot of groups struggle with.

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And then lastly, uh, the practice
management software tool, uh,

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is also, uh, a common pain point. You
know, we talk about autonomy again,

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you know, a lot of DSOs don't wanna
make their offices change. And so they,

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you know,

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we see some DSOs that have eight to 10
different practice management tools.

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And so it's,

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it's very challenging to support all
of those different tools to try to get

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accurate data, uh, and timely reporting.

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And so we really recommend you gotta
consolidate, get everyone onto one tool.

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But even then, once you
get everyone on one tool,

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how staffs use the tool
can vary very greatly.

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So you've gotta have
a common practice, uh,

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for how everyone's going to use the
tool, how we're gonna set up customers,

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what data are we collecting, uh,

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what codes are we gonna use to correlate
with the appropriate procedures.

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So all of the reporting issues that
we hear DSOs complaint about usually

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stem from not using the
p m s tool correctly.

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So it's important to get everyone
consolidated on onto one tool,

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and then it's important to use that
tool effectively. And then, you know,

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creating that standardized process, uh,
so that we can get to the valuable data.

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So yeah, integration, R C M P M S
tool, those are, those are things that,

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that most groups are struggling with.
Uh, and they're, they're key, uh,

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if you truly want to
grow in this environment.

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Absolutely. And it sounds
like they're key also to, um,

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ensuring payments are
collected in a timely way.

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I think you had mentioned that earlier,
so, seems like Absolutely. Yeah.

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So considering those three areas,
you know, having an integration plan,

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revenue cycle management, the p m ss, um,

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are there any specific stories or maybe
even case studies that come to mind that

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highlight an organization that did really
well or improved one of those areas?

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Uh, maybe one of your partners at
E 78 had some remarkable outcomes.

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Yeah, so we actually just, uh,

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a couple of months ago released a case
study on one of our clients, US Endo. Uh,

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they have recently rebranded
their specialized dental
partners now, uh, but to,

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uh, they were, we were with
them from the very beginning.

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So they knew they wanted
to start an national D S O
that focused specifically on

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endodontics. And so they had a
very aggressive growth strategy.

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They wanted to grow specifically
via acquisition. And so
when they contacted us,

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they had one practice under,
uh, L O I and as a company,

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they had no infrastructure built yet
to support their growth strategy.

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So they basically came to us
and asked to partner with us.

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And so we became their back office
team and their integration team.

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So started by creating a framework, uh,

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that would be scalable and provide
flexibility when they integrate these

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practices. And so that included
the, their e r p selection, uh,

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designing the tech stack to
support the growth strategy,

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and then standing up an HR
team to manage the people,

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the payroll and the benefits. So we were
there, uh, you know, from day one, uh,

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and helped them grow from one location
to 400 plus. So it's an interesting read.

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I would encourage, uh, listeners to
go check it out. Um, because it, it's,

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it talks a lot about some of the, the
pain points that happen along the way.

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And so, you know, for us, we love
to be there in the beginning, uh,

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because it's easier to build from
scratch than it is to change mid-course.

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But we also have a lot of clients that
have gotten to 40 or 50 locations,

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and they've kind of become
stuck, right? They fully,

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they haven't fully integrated all
of their offices. So, you know,

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they could be struggling to
close the books on time, uh,

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month in might be taking too long, uh,
because they have multiple data systems,

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they can't get accurate
reporting, uh, or maybe, uh,

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because of there's so
many manual processes,

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their back office staff has grown so large
and it's killing their profitability.

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So those are all common issues that we
see. And so for those groups, you know,

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we've had success, uh,

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doing what we call a current
state assessment where we
go in and evaluate their

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people, evaluate the processes,
and we evaluate the technology.

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And so from there,

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we can kind of create a gap analysis and
just understand what's the root cause

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of the problem, uh,

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and then ultimately identify what
changes they need to make to be more

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efficient. And so those are, uh, that's,

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those are the kind of the
two areas that we focus on.

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We'd love to be there day one, uh,

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but if you're a little bit
further on down the road,

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we can certainly come in and support
you and meet you where you are.

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Yeah, that's great to know,
Duff, I appreciate that.

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And pretty remarkable having
us Endo grow from one to

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400 plus <laugh> practices and Yeah.

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Yeah. And I'll tell you, the, the
great thing about it is, is it,

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it's not always rosy. So we learned a
lot of problems along the way mm-hmm.

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<affirmative>. And so
the good thing is, is,

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is we can tell you what
pitfalls to avoid, uh,

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because you can't grow that big that
fast without having some challenges.

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And so, you know, we embrace
those challenges head on.

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We've learned a lot from
'em. Uh, and, and we,

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we can't wait to share those
best practices with, with others.

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Fantastic. Well, thank
you so much. And, um,

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perhaps in the description
for this podcast episode,

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we could potentially link the case study,
or at least route listeners that way.

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Um, but before we hop off, you've
shared so many great insights.

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Is there anything else that you'd like
to share with listeners before we close

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here?

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You know, I, one of the common
question I get from, from DSOs is,

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is they wanna learn about what they should
be thinking about what they should be

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doing, but they don't
wanna go to a website and,

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and have to fill out a form and, and
get called by by salespeople. Uh,

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and so there is a group, uh, that
I'm a part of, it's called, uh,

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dental Vendor Industry Network.
Uh, initials are D V I N.

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And ultimately it's a website where,
uh, people that are in the industry, uh,

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can post information about
what they do, who they support,

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and DSOs can go there without
the fear of being pitched to.

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So it allows them to, to see
what's going on in the industry,

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to see who some of the vendors are
that are supporting, uh, the industry.

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And it's really designed to be a,
a collective, uh, environment, uh,

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so that everyone is helping everyone
out. And so I would encourage,

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if you're a D S O and, and
you're struggling in some
aspect of your business,

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go check out the D V I N
website and, and see, uh, who,

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who works in that area and,
and what vendors are there.

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You can research and learn about
them. And then if it makes sense, you,

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you control the reach out, you don't
have to worry about being sold to. Uh,

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I'd love to promote that because it's a,

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it's a good group of people and everyone
in there is in the dental industry,

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has dental experience, and they're looking
to help grow the industry as a whole.

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That.

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Sounds like a really great resource,

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and I think our listeners will
appreciate that, especially the, uh,

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not having to fear getting pitched to,
as you mentioned. Um, so Exactly. Yeah.

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Thank you so much again, Duff,

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I really appreciate the time that
you took to be with us today and your

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insights. Thank you again. Yeah.

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Thank you for having me.

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We'd also like to thank our podcast
sponsor today, E 78 Partners.

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You can tune into more podcasts
from Becker's Healthcare
by visiting our podcast

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00:19:10,970 --> 00:19:13,460
page at becker's hospital review.com.