Creating Sustainable Success in Attracting and Retaining Associates at a Group Dental Practice

Owning and operating a group dental practice brings with it a myriad of challenges, but arguably the greatest centers around associates. Success often means creating and executing a plan to minimize associate turnover. Too many—from enterprise-level dental service organization (DSOs) down to emerging, doctor-founded groups—seem to be a revolving door with dramatic turnover rates.

Where do you even start? Maybe right here…

The State of Associates

We’ve all seen the statistics from the American Dental Education Association (ADEA) as well as other agencies. The ADEA research from 2020 states that 82% of dental school seniors graduated carrying an average of almost $305,000 in educational debt. That’s staggering, and probably accounts for the reason that “30% of the graduating seniors plan to join a DSO” (ADA’s HPI), up from 12% only 5 years ago.¹ I don’t blame them for not wanting to buy their own practice and add on a significant amount more to their already sizeable debt load.

In my role at Polaris where we help entrepreneurial dentists build and exit successful group practices, I get to work with practices facing these challenges every day, and I can see the pressures facing both new dentists and growing dental practices.

Since 1997 we have added 13 new dental schools and 2020 saw a record of first year enrollments at over 6,300. Couple that with the fact that, for the first time ever, less than half of dentists now own a solo private practice.

The conclusion is inescapable: for those who building group practices, you’re going to have a lot of associates to potentially hire.

Becoming a Recruiter

Is recruiting one of your top 3 priories, or is it an afterthought until you’re in need? Be honest with yourself.

The best companies—be they corporate America or group dental practices‑—make recruiting a priority. They realize it’s a never-ending process. The goal is to always have more viable candidates than you have openings. Those candidates must come from a variety of sources: referrals from current associates; study clubs and dental societies; the military; dental schools other than the one closest to you; 3rd party advisors; recruiting agencies; social media, etc. How many sources do you have in your network?

Creating Certainty

Young Associates are in high demand, and they know it. The question you must solve is: Why should they choose you?

Most professionals don’t react well to uncertainty, so create clarity for them.

• Clear compensation plans – You pay 30% of collections whereas the other group is offering 35%, but if your first year Associates average $800,000 in collections compared to the other group’s average of $600,000, where will they make more income? Back up your comp plan with take-home income data.

• Clear onboarding plans – What happens during their first 12 weeks on the job? Who is their mentor, and what about the skill and experience of their dental support team? Show them how quickly you will integrate them into the team.
• Clear clinical development plans – Beyond onboarding, what is your clinical development plan for them over their first 2 to 3 years? Most want to “master their craft,” so lay out what that path looks like in terms of advanced skill development along with timeframes and investment (from both sides). They’re not too far out of school, so think “curriculum” here.
• A clear vision for the future – We all want to be part of a winning team, so share your vision for where you want the business to be in 3 to 5 years, then relate it in terms of how you see them being a part of it.
• Clear core values – Do you really want someone who doesn’t care about your core values? Peter Drucker’s quote, “Culture eats strategy for breakfast,” has never been more true. If it doesn’t matter to you, don’t expect it to matter to them.
• A clear plan to becoming a partner – Most dentists are entrepreneurs at heart and they desire to be business owners. They want to have a stake in the future they’re helping create, so you’re at a disadvantage if you don’t have a structure that facilitates them earning in or buying in to your business.

There’s a lot more than just what I’ve outlined above, but the key is that you want them to want to be part of what you’re building. Help them see themselves being a part of it. Make it so they can’t imagine working anywhere else.

Looking Like a Professional

If you’re building a group practice, you’re competing against seasoned HR professionals at the top of their game. Verbally walking a candidate through everything about your business, then giving them a copy of the comp plan with an employment contract isn’t going to cut it.

Have everything about your business laid out coherently in a 10+ page presentation that answers the question: Why you?

Make a PDF of it. Print it with a clear cover and spiral binding. And then give them a copy to take with them, so they can refer back to it (hopefully often). People learn visually and don’t retain nearly as much audibly, so always have something to give them that represents you long after you’re gone. Honestly building this presentation is one of the most fun aspects of my role at Polaris working with clients because it brings to life aspects of their business that are special, but they often take for granted.

Pathways to Partnership

I noted earlier how much debt the typical new dentist is carrying and that they probably didn’t want to add more to it by buying their own business. However, that doesn’t mean they don’t want to become an owner. Quite the contrary, they do, and they will, just maybe not with you if you don’t have a way to make that happen.

There are basically 3 ways to crack the associate equity nut: traditional buy-in; earn in through Restricted Stock Units; or earn in through Profits Interest Units.

Traditional Buy-in

This is pretty straight-forward. Your business is valued at $10,000,000. You offer me the opportunity to become a 10% partner. I borrow $1,000,000 from a bank to buy in. Depending on the loan covenants on your existing debt, you may not be able to “pocket” that $1,000,000 from my buy in and may have to use those proceeds to pay down existing debt. Also, while I (as the Associate) would personally guarantee the loan, the business would ultimately back-stop it, which could create complications on the overall amount of debt you could borrow for future expansion. Something to think about, depending on how quickly you intend to grow and what your current leverage scenario is. As you can probably imagine, we work with clients frequently on debt recapitalization in an effort to secure more committed growth capital as well as cap table mergers and/or Associate buy ins.

Restricted Stock Units (RSUs)

I was the beneficiary of these during my time in Corporate America and they’re quite popular in publicly traded companies. RSUs are “real equity” and not phantom equity. They’re performance based and they have a vesting schedule (“golden handcuffs”).

In a group practice, the concept is that the Associate has a collection goal and for every dollar above that goal, they earn some percentage in company stock. The goal goes up every year, so they can’t “ring the bell and coast.” Every share of stock they earn has a vesting schedule, so it becomes theirs gradually over time (usually 3 to 5 years). If they leave, they forfeit the unvested shares – which is the built-in retention mechanism. The founder ultimately takes dilution, but the increase in the value of the shares should offset any dilutive impact. Think of it this way: Would you rather be the 100% owner of a business valued at $5,000,000 or the 80% owner of a business valued at $10,000,000? There are a lot more details, but you probably get the idea. These models work very well for growing groups with established practices.

Profits Interest Units (PIUs)

Similar to RSUs in terms of a goal and the vesting concept, but arguably better suited to a De Novo model. The goal is more of a threshold of EBITDA and Valuation. Every dollar of value below the goal accrues to the founder, but they split any dollars above the threshold with the Associate. The split percentages are a variable in the model as are the thresholds. Again, a vesting schedule ensures you retain the Associate for the long haul. As with RSUs, there are a lot more details, but hopefully you get the concept.

The overall point here is that in today’s world of associate turnover, you really must have a partnership solution in place. It won’t cure your turnover 100%, but you’ll arguably be able to recruit a higher level of candidate who will work harder and stay longer.

And if you can do that, it’s better for patient care; the continuity of the business; and your sanity.

Reference

1. Munsen, Bradley. The Changing Dentist Workforce. American Dental Association Health Policy Institute. March, 2022. Accessed May 20, 2022. https://www.ada.org/resources/research/health-policy-institute/dentist-workforce/the-changing-dentist-workforce.