Hello, and welcome to the Becker's Healthcare podcast.
My name is Chanel Banger. And today, I
have the pleasure of speaking with Avi Weisbogle,
the founder and CEO of Restful, powered by
International Academy of Sleep. Avi, thank you so
much for being here today. Please. My pleasure.
Looking forward to it all. Perfect. Well, to
get us started, can you please introduce yourself
and tell us a bit about your background?
Sure. So as you said, my name is
Avi Weisvogel.
Like a lot of people, I went to
dental school. I am now a recovering dentist,
by the way. I went to dental school.
I graduated from NYU in 1998.
Did a residency for a year
and then started my journey down private practice
lane when it was actually easy to own
private practices because then you could just kind
of open a practice
and
profit came. I I was kinda crazy because
I knew nothing about business. And yet day
one in my private practice, which was the
day after my residency, somehow I was making
a profit.
That is kind of what played into my
story a little bit. At some point down
the line, sleep apnea became a passion of
mine.
I took a lot of courses on it,
and no matter what I tried to do
by going to these courses and asking questions,
there was no path. Like, no. You wanna
you wanna succeed in sleep apnea, go figure
it out.
And,
I will say unlike a lot of dentists,
I spent three and a half years banging
my head against the wall, like, determined to
figure this out.
Ended up building a big sleep company. So
instead of practicing dentistry,
the long five days a week that I
was, I started practicing dentistry one day a
week, spending the rest of the time on
sleep apnea and building up a big business
surrounding that. I sold that business and then,
had a non compete, and all I could
do was teach. So I started teaching people
exactly what I did,
and that was the International Academy of Sleep,
the company I founded. We just teach dentists
and consulted with them on how they could
big,
build really big sleep practices. This is in
addition to their dental practice. Kind of had
a formula
that if a dentist was gonna spend four
to six hours a week on this and
do what we were asking them to do,
they'd be able to be successful at sleep
apnea
in addition to owning their dental practice.
This was not for everybody. It was an
expensive program, and we put it together
knowing that those who did it would succeed.
In the end, if you look at the
top 10% of producers in dental sleep medicine,
literally almost all of them have come through
that program because we focus on the business,
not the clinical. Clinical is easy. If you're
not a dentist, I'm assuming you're not. I
could teach you how to make one of
these appliances in two hours. Oh. You'd know
how to do it. You'd be as good
as anybody.
That being said, the business end takes time,
and it takes a lot of learning, and
it takes a lot of patience
because there's so many steps to get there.
As
iOS was a lecture company,
we would lecture to bring on new members.
New members would commit to us for a
four year period for a, large sum, about
250 k if they wanted to do it.
That's what we felt it took to succeed.
One thing that was always missing
was a good EMR for sleep. Dentrix is
not, I you know, Eaglesoft is not. There's
the EMRs that were out there were not
sleep based. There were a couple that were
out there, and they just were not very
good. So it was always like, hey. Why
don't you create a software?
And I'm like, yeah. If only I had
time. And then all of a sudden, the
whole world changes, and I had time on
my hands. Because instead of lecturing
every other weekend,
I was home for a period of about
four or five months. And we went down
this journey of building RESTful, the software.
RESTful was originally intended to just be that.
Like, a place where the the goal was
as follows. If a dentist used RESTful,
they would be able to do the steps
that they needed to do in order to
let somebody else bill for them. Because it
does require two things. One, the dentist has
to do their things the right way, and
they're usually not taught the right way. And
even if they are, there's so many shortcuts
they could take that dent they love the
shortcuts, and that would lead to them not
getting paid. So I'm like, well, at least
if we have the software, the dentist would
have to do things their way. Turns out
that was just the beginning. It's now morphed
into an entire full on service
where not only does it do that, we
also pick up the billing end for you,
and our team will bill it. So it's
like, hey. Software forces you to do what
you do well, and it also allows us
to do our part really well. So now
we introduced something to sleep that was not
there. And that's what this has to do,
by the way, with the DSO world, Predictability.
Right? So I am also in the DSO
space.
Along with, partners of mine, we have created
three dentist owned DSOs in the past eighteen
months, couple more to come. And then all
of a sudden, I got this great idea.
Hey. Why not marry these two worlds that
I work in and love both? I love
the sleep world to change my whole life.
Otherwise, I'd probably still be sitting there, you
know, pulling out hairs while
figuring out ways to survive
in a world where DSOs are kind of
dominating the space, and it's tougher for the
solo practitioners to evolve.
So if I could marry these two worlds,
well, now at least I'd be working on
everything I'm doing kind of in the same
space,
in order to do that as I mentioned.
The DSL model is simple. Right? We love
predictability.
Dentistry is predictable and profitable. Right? Private equity
comes in. They spend they're willing to invest
their money. And if they can get that
return, right, a normal GP practice is like
an 18% EBITDA, and a specialty practice maybe
around 25%.
So if private equity knows they're gonna get
that kind of return and then eventually be
able to flip their money for even a
better return, that's interesting to them.
But they stick to bread and butter simplicity.
Now I can tell you that every DSO
out there, all the big ones for sure,
have at least been pitched on sleep apnea.
Probably most of them have tried it, and
all of them have failed. None of them
have ever been able to do it because
there's so many steps from the training of
the dentist to the training of the team
to making sure that somebody is looking out
for the changes. Like, so I told you
I could teach you an oral appliance in
two hours. Let's say I taught you everything
I knew about
the billing and insurance, and that'll be good
for about six months. So somebody out there
has to be looking to say, hey. There's
changes coming. We're gonna have to put those
in place. So now for me, I am
able to bring these two worlds together where
we work with a lot of solo dentists
still on building sleep. These are the dentists,
by the way, who don't wanna sell it
to a DSO. They're just looking for a
way to survive. And then the DSOs that
we've created as well as other DSOs that
we've spoken to, we believe we have an
opportunity to do something that nobody's ever done,
get them successful with sleep. So that's, that's
a long intro of what gets me here.
But, you know, I didn't go into, like,
kindergarten or any of that stuff. So
Love to hear it. Well, kind of in
that same vein, what makes dental sleep medicine
such an opportunity for DSOs? You've kind of
already touched on it, but can you go
into that a little bit more? So first
off,
you know, there's two ways of growing EBITDA.
We all know it. There's the organic way,
and then there's going out and buying EBITDA.
First off, it is
competitive right now if you wanna go out
and buy EBITDA. There's less and less of
the really good practices available.
I don't know what the actual numbers are
in terms of how much the DSOs own.
But when you look at practices that are
sold by brokers, they're always the same thing
right now.
Amazing opportunity. $1,000,000
for operatory practice available here. There's no $2,600,000
practices available because when a broker gets that,
they go straight to the DSOs with it.
And now there's less and less of those
available. They're all getting bought.
That's just kind of life. So then we
start looking at different ways. Well, how can
we grow organically? Now everybody does the same
thing. Right? Hey. We're gonna do centralized systems.
We're gonna put a couple percentage here, a
couple percentage there.
Most DSOs look for people that can place
implants, and if not, they wanna train them
to place implants. And most DSOs do Invisalign,
that's a procedure.
This is the easiest procedure. Like, doing a
sleep apnea appliance is the easiest procedure a
dentist can do. Really easier than doing a
filling because it's just a scan of the
teeth done by their team pretty much. Consult,
scan, insert this perfectly fitted device,
all is well. That is, by the way,
ninety eight percent of the cases. So are
there gonna be some complexities? Sure.
And in those cases, if you're not trained
up, you might have to ask for some
help. But it is ninety eight percent of
the cases. So no different than if a
dentist is working on a patient and something
comes up that's out of their scope. Right?
They refer it out. Anyways, in this case,
the profit margin on sleep appliances is astounding.
Like, it's over $3,000
profit per device.
Now the numbers vary. If you look at
any population, it's like at least ten percent
of the population has undiagnosed sleep apnea,
with that are candidates for oral appliances. More
that are undiagnosed sleep apnea that might need
a CPAP, but candidates for oral appliance.
I mean, just imagine the numbers. You know?
Imagine if all of a sudden ten percent
of your patients,
you are able to make an extra $3,000
on each one.
I'd say really good opportunity.
You know? And, also, listen, it's how many
GP DSOs are there out there? Now thousands
of pump. I don't know. There's a lot.
Probably not thousands. A lot of them. And
what are they doing to distinguish themselves
from the next one? It's typically the same
thing. Now we do know that that is
typically something private equity invests in. But if
all of a sudden somebody's doing something different
and they have a way of showing, well,
we got something different here. We're doing sleep
apnea appliances. We're doing them well. We're doing
them predictably. They're easy for us. They're profitable.
I mean, who wouldn't want this is my
thought.
Absolutely. And when you're presenting this to the
establishment, how do you get them to see
the advantages over the disadvantages?
Yeah. So the first thing I have to
do is tell them I know that they've
tried it already. And I know that you've
heard this pitch, and that's not ever a
fun thing to do. Because when I was
first starting to work with dentists,
I would get the same call every time.
You know? So they would see one of
my ads, and they would call me up,
and they say, well, you know, I tried
this already. It doesn't work. I'm like, well,
tell me what you did. Well, I went
to a course.
I did everything they told me to do.
I treated three patients, sent them to medical
insurance, and got denied. Now there's a little
known fact. If you send as a dentist,
you send a claim to medical insurance and
it's the first claim you send, it is
getting rejected. I don't care what it is.
It can be an oral appliance. It could
be an oral cancer screening. It's gonna get
rejected. There is a system where in order
for dentists to play in the medical insurance
world that they have to follow that, frankly,
most people don't know and or understand. So
So now we're working against the fact that
most of the DSOs have probably tried it,
heard it, spent money on it, by the
way, because to train a team of, you
know, 100 dentists and, you know, 500 staff,
that's a lot of man hours that goes
into training them. So we have to get
over the fact that they've spent money, lost
money.
But, you know, what
I would never have told anyone until we
got this process going was that this was
predictable. I would have never said it. I
would have told everyone, hey. Listen. The this
is gonna very much vary based off of
you. I don't know how hard you're gonna
work. I don't know how much your team's
gonna put into it. Now we don't need
very much. So we did a panel here
at Becker's here this weekend.
And one of our DSOs that we started,
the CEO was here, and he said, you
know, when it comes to sleep, you don't
necessarily want to invest
in this team member who you're all of
a sudden gonna have to train, and you
don't know if that person's good and or
even fits your team or fits the rest
of your team,
Russell kinda becomes that team member for you.
We have that ability to just
be the person that's going to help you
take this to another level. Everyone gets a
billing,
executive that is assigned to them if you're
a DSO, obviously, or if you're a dentist
that does large numbers, which are probably only
about a 100 that do really large numbers.
But, you know, when we start working with
the DSOs and we want them to start
screening their patients, we gotta train the dentist,
we gotta train the teams, We gotta support
it all. We gotta show them how to
use this because it is another EMR. It's
not just an adjunct. The only one that
it does work with if you're, someone who
has an EMR is Open Dental because, well,
it's open. You know? Open Dental makes life
easy. Like, hey. Here's our API. Go to
town. You know? Every other place is very
secretive, so it doesn't work.
But, you know, we wanna be able to
show that this is sitting there.
You don't have any other thing in your
waiting room that's sitting there. Not one other
procedure. Doesn't exist. There's no other procedure you
could go out and learn that is this
easy
and this simple, and it is simple now.
The hard part was always the business end.
We've taken that and just made it really
simple. So we educate the dentist. We say,
hey. Here's what you gotta do. Follow this
thing that says step one, and then finish
it, and then that lets you go to
step two. And it won't let you go
to step two if you didn't finish step
one. So now we're training the dentist to
just click buttons pretty easy. Right? And then
we have our team on the back end
who's going to work with the team there
to say, alright. Here's the few things I
need you to gather from the patients. Here's
the one or two things I need the
doctors to do. It's all guided by the
software. And now we're gonna get you paid
and get you paid probably in, like, record
timing. So when I had my business, we
were always three months behind. I would get
paid three months behind because everything was slow.
Now we're, like, three weeks behind, which is
not that different than normal dental insurance. So
I I think it's a major advantage.
The disadvantage is probably you've tried it. You've
probably lost money on it. You may not
have not every dentist is gonna wanna do
it. You know, you can't force dentists to
do things. We know that is not a
model that works in the DSO space. We
want dentists to do dentistry and concentrate on
it. This is just an easy thing for
them to do at. And because, listen, most
associates are paid on collections,
if you're collecting 3 to 4,000 and it's
that 30 percent model, this is easy money
for them too. So it just works all
the way around.
Got it. So it sounds like they kind
of outsource the headaches to you guys. Yes.
Very much so. Bring your headaches on. We
love them.
Well, yeah. I've enjoyed our conversation so far.
But to wrap things up, can you share
any advice to anyone from the executive suite,
and DSOs to the chairside dentists who think
the promise and possibility of dental sleep medicine
on a larger scale is overrated or exaggerated
or just can't be as fulfilling as described.
So
and we have to face those truths. A
lot of them have tried it. A lot
of them have failed.
What I would say, this has to be
worth a conversation.
It just has to be, you You know?
Hey, Avi. Tell me what's different. What do
you do now that's different than that program
who came to us three years ago and
promised the world,
and charged us $200,
didn't deliver on? And so we would go
through it. We'd wanna hear what they've been
through, and I know what they've been through.
A lot of clinical training. That is really
what when somebody introduces sleep, that's what they
do. They train the dentist.
And they don't fully train the team, and
I'm saying it out loud because they don't
really know how to. You know, they are
the the rules are constantly changing, and every
insurance is different. So our software kind of
has all the insurances built into them, and
each one has a different protocol. So you
just have to follow that one. Like, you
know, you live in Idaho.
Go to the drop down box for Idaho,
pick the insurance. It'll kinda guide you through
that. That took us a long time, by
the way, to go through all that. I'm
sure. Yeah. An extremely long this was three
and a half years till we could launch
it because of all this silliness. Different markets.
Yeah. Different markets, different insurances, and changing insurances.
We could get it straight. Listen. Imagine,
a world where the first iPhone came out
and they gave it to you, and you're
like, here you go. You're set for life.
That's not what happened. Number one, there was
a software update every single week. Number two,
there's
constantly new iPhones out there and
bigger, better, different, maybe a little less different
now than they used to be. But, you
know, always something better out there. The dental
sleep software world was the iPhone one. We
built this product. It's great today, and it's
obsolete in six months, and we're not willing
to spend on. Restful is never gonna be
a finished product. Just won't be. We understand
this world. We understand this world's always changing.
We're changing with the world. Yeah. There's constantly
rule changes. And those rule changes are done
for one reason. They don't wanna pay you
insurances. Medical insurances do not wanna pay dentists.
Promise. They don't. They're gonna try and find
a way to reject. So if we have
a way to get around those rejections by
following the rules,
insurances have to pay. So to me, it's
at least worth the discussion.
Sure. We can help talk to the dentist.
I would expect in a DSO that has
a 100 dentists, maybe 10 of them are
interested in trying it. Go pilot it there.
You don't have to do a full on
commitment, you know, where if you have a
thousand locations, all thousand must do this. It's
not realistic.
It's realistic to pilot it with a few
that wanna try it. Let them be the
proof of the pudding. There is this isn't
gonna be anything that's backbreaking from an expense
standpoint. And if you give it six months
to a year, you're going to see the
benefits from, a, a financial end. And I
will tell you that this creates other procedures
for you. So I had stopped doing general
dentistry in my practice because I didn't have
time.
And all of a sudden, I started getting
all these patients referred to me
because of sleep. Right? So they were coming
from doctor's offices, not just from regular sources.
Now I always say this. Imagine you're in
a hotel like this, and we tap somebody
on the shoulder and say, do you go
to the dentist? About 50% of the people
in the world don't go to a dentist.
Wow. Yeah. It's crazy. It's like 50 go,
50 don't. It tends to be the ones
with insurance. They all go. However, you got
a room full of sick people. You know
how many of them go to the doctor?
All of them. Yeah. And so it's like,
all of a sudden, these patients started coming
into my office
that
needed a sleep appliance.
The reason they weren't a candidate for it
yet, and we put them in a temporary
device, was their teeth were a mess.
So I started doing all these full mouth
rehabs on these cases that started coming into
my office as referrals.
It created a whole huge boom. It was
the single biggest builder of my restorative practice
as well as just being a big business
that, listen, it's gonna set you apart. It's
gonna be something that when all of a
sudden they look and they say, hey. How
did your EBITDA go from here to here
in a year?
We saw you only bought
10 new
practices.
There's no way all your EBITDA came from
there. Where did it come from? Now all
of a sudden, we have something different to
pitch. Now all of a sudden, we may
be a little different than your standard GPDSO.
I mean, specialty markets are doing great. Specialty
DSOs are doing great. That's unique. That's different.
This is a chance for any DSO to
really start to either stand out and or
just, hey. You wanna increase what you're doing
now. It's better. It's great for your patients.
You know, the most loyal patients you have
are the ones that you get to change
their world. Right? So this is a stat.
The average sleep apnea
patient that is treated
versus someone who's diagnosed and untreated or just
undiagnosed,
the treated ones live on average eight years
longer.
I mean, that's life changing. You know, you're
in the store and all of a sudden
there's something on the shelf that says eight
years of life. What are you paying for
it? And the quality of life has to
go up Immediately. Significantly. Yeah. Yeah. And if
you're interested in it, your spouse won't despise
you anymore. It just won't keep them up.
Yes. So, like, I not everybody who has
who snores has sleep apnea, by the way.
I am told I snore, so I wear
an appliance.
I don't have sleep apnea. I've been tested
hundreds of times. There's, you know,
there's a level that they call sleep apnea,
and it's dictated by the insurance companies, of
course. It says if you stop breathing five
times an hour, you have sleep apnea. If
you stop breathing 4.9 times, you're considered not
to have it. So, obviously, there's something missing
there. But
when I wear my appliance,
I feel better, plain and simple. So it
does change quality of life. I'm better rested,
more ready to go out and go get
them. And it just because there's those patients
and that loyalty factor, you know, kind of
everything we're looking for. You know what I've
heard over and over here this weekend? We're
all about the patients.
We're all about that customer service. Our patients
are everything to us. Well, you're skipping one
big thing that you could actually do for
them that's really gonna make them loyal. And
if you got the chance to do it,
grab it. It's gotta be worth the conversation.
You got nothing to lose.
I don't expect to talk to, like, a
large DSO one person and then all of
a sudden have a yes. There'll be a
variety of meetings that we get to to
get to a pilot program, and hopefully, that
would make sense for, in my opinion, everybody,
but for at least those who are willing
to take the chance.
Love to hear it. Well, Avi, I wanna
thank you once again for your time today
and for sharing your insights on the Becker's
Healthcare podcast. Oh, my pleasure. Thanks for having
me. And we also wanna thank our podcast
sponsor, Restful,
powered by International Academy of Sleep. We hope
you have a wonderful rest of your day
and look forward to having you tune in
to future episodes. Thank you so much. Thank
you. Appreciate it.