Dennis Hartlieb

Managing Multiple Practices.

Today on the sharecast, Dennis speaks with AJ Acierno about managing multiple practices. Here is what we talked about:

  • The #1 metric to consider when purchasing a dental practice
  • If you are a solo practicing dentist, what is the key number to look at when deciding if the time is right to bring in an associate
  • What every dental student and young dentist should do prior to joining with a DSO
  • Options for dentists when selling to a DSO
Dr. Hartlieb: AJ, I'm going to get a little ahead of myself. And I want to give our listeners a little bit of your background. So I met AJ probably about 20 years ago, I think that sounds nearly right?

Dr. AJ Aciermo: That sounds about right. Yeah.

Dr. Hartlieb: Yeah.

So, AJ is a graduate of the Creighton University undergrad and dental school, as I recall. Then he came back and took over a practice. I got to know AJ through the study club.

The reason that I'm asking AJ to join us for today's Sharecast  is because AJ has become somewhat of an expert actually on DSO’s. He has really a unique style, and he'll talk about his style of DSO.

But I wanted to bring AJ in because I know a lot of our listeners and readers are either involved with DSO’s, as young dentists, or dentists who are looking to create group practices. So I want to talk about that from both standpoints, right from someone who's really young and getting into it, and people who want to be able to grow into more practices. Before we start, though, let’s talk about AJ. He's the co-founder with his brother Michael, who's also just another excellent dentist, and just an excellent guy. AJ is the CEO of Decision One Dental Partners. And I believe now you're over 30 practices, is that correct? And I believe they're all in the Chicago Community at this point.

Dr. AJ Aciermo: That's correct, but we've ventured into Wisconsin, we have one up there as well.

Dr. Hartlieb: Fantastic. So, AJ is the only person that I know, personally, that's done a TED talk. I think that is so cool. And I am so jealous, because I love TED Talks because they’re right to the point. And you had a great title: “Healthcare Has Lost Its Soul”. And that is so accurate. If you have not seen this, you can go on YouTube and search for “TED Talks” and “Healthcare Has Lost Its Soul”. I believe its maybe one of the core values or core features of your DSO, which we'll talk to you about that in just a little bit. And I know you've been a guest on numerous podcasts, and you've been interviewed a bunch of times. So this is old hat for you, but I can't thank you enough, truly, for joining us today. And sharing with us your wisdom.

Dr. AJ Aciermo: It's my pleasure. My pleasure. And I'll tell you what, it didn’t seem too long ago that we met, but then you just said it’s been 20 years since I went into your practice, and man, the amount that I learned in just like a four hour period in your practice watching you work was amazing. And it was just, it was pretty amazing. The work that you're doing is tremendous.

Dr. Hartlieb: Well, thank you very much. So AJ, I'd be remiss if I didn't ask, given that we're taping this or recording this at the end of the first summer of COVID-19, How are you and your family? How's everybody?

Dr. AJ Aciermo: Everybody's good. Everybody's safe so far. Knock on wood.

Dr. Hartlieb: And your teams at all your dental practices?

Dr. AJ Aciermo: Yeah, teams are good. I mean, you know, running a healthcare company during a pandemic is probably not the place that you really want to be, to be honest with you. It's tough. We've had to make really, really tough decisions when you're running any company in America right now, or the world I should say. But understanding that you're dealing with emotions, and a lot of people because everybody has different emotions. Our patients have different emotions. Our team members have different emotions.

So you're managing people more than ever, and you're managing the psychology of people but now you're actually managing an economic crisis, a pandemic, and all the other things that come along with what we're going through. So I can tell you that every day is a different day. Like you could wake up in the morning and my daily schedule listed out for me. And I can guarantee somebody by the end of the day that schedule doesn't look anything like it did before.

Dr. Hartlieb: Let me ask you a question: You talked about your team members and patients. Tell me about the emotions you went through.

Dr. AJ Aciermo: So you know, the weight that I have on my shoulders...I have 350 people that rely on me and the decisions that we make to have a paycheck. That's a large weight that you go to bed with every night. And when this all happened, for the first time ever, our revenue source just got strangled off. So you know, I always tell everybody that the ramp down was easy, right? Everybody knows that the pandemic, it's like, “Hey, everybody, we got to furlough.” We tried to help them into unemployment. And you know, that part was really easy. I say “easy”, but emotionally, it was draining. Like the baby that you just built for all these years, is right now, on life support because of an outside source. I always imagined that I'd wake up in the morning, look, myself in the mirror, go, “AJ, you screwed this thing up,” right? And I would have to deal with myself. It was very emotional to go through the thought “I can't believe something on the outside is actually taking down the thing that we all built together.” All the dentists that are in our group and built this thing, and now this is where it's at. And so the ramp down was emotional.

The ramp up, super strategic. I mean, financially strategic, PPE strategic, and so on. We're having conversations overseas in Europe, China, Australia-- we were all over the world, just trying to figure out how this is going to work. We were watching Europe and their ramp up-- how did they do? We watch China and their ramp up-- how did they do? We had to go ahead and start securing PPE over in China. I never imagined that I'd be waking up at three in the morning-- And I mean, I did this 50 times more-- waking up in the middle of the night having conversations with people in China saying, “Can you get me this secured by 4:00 tomorrow?”. And can it get on a ship by that time, you know, and then watching the ship. And looking at it and finding out that your stuff just got stolen in Europe. And now you're now you're calling back and then then it gets to the United States. And then it was commandeered in the United States. That was the worst part. The ramp up was the hardest.

Dr. Hartlieb: That's interesting. I just own one practice. There is an emotional sucker punch to the gut for me, having to furlough or lay off our staff. And I had a little bout of what I would say was depression. I was definitely down. I was definitely sad. I was saddened by the whole event and my lack of being able to have control. So it sounds like a lot of what you're going through, then as you're trying to ramp back up, is sort of this lack of control. And we'll talk about this in a bit. Because I think this is a really interesting thing as we start talking about having multiple practices and having control. Yeah, but I have to imagine that had to be just incredibly upsetting for you, given that what we do as dentists is all about what we can control. And then someone who has multiple practices about being able to control these things. And now these things are out of your grasp. And that had to be just really just incredibly challenging for you.

Dr. AJ Aciermo: Yeah, I mean, I think we're all gonna Monday Morning Quarterback, some things, Dennis, I made no secret that I was unhappy with the representation that dentists got all over the United States. How we were not deemed essential. It was crazy. Actually this morning at 10am, I had a meeting with Drew Ferguson, Dr. Ferguson, who's a congressman out of Georgia, who's a former dentist. And, you know, we have dentists-- there's five dentists in Congress right now. And so we had five dentists screaming amongst everybody “Hey, you're missing the boat here. How are you deeming this non-essential? Are you guys crazy? If this ends up in the hospital, do you know what's going to happen to the hospital?”. Honestly, we were lost if it wasn't for those five dentists in Congress. Man, we would have been way, way deeper in trouble.

I sit on the Board of Directors for the ADSO, which is the American Dental Service Organization, which has all the DSOs across the United States part of it. We're doing a lot of work with lobbyists and our Congressmen. We're just advocating right now for dentists to have a seat at the table.

One of the greatest things about it is that it's a doctor-patient relationship. Right? That is the greatest thing. You know, and nobody understands that until you're just you and the patient in a room taking care of somebody in your hands in their mouth. That's the special connection that we have. You want to keep that. But dentistry has always been kind of the stepchild, or the second, when, when discussing healthcare for sure. I've been on the calls, right? Like we were in the midst of a pandemic. And they were talking about fit testing of N95. And should we get it or not? And should we get N95 masks? What happens with essentials? And you're sitting there and you're going “Well, wait a second. Excuse me, Congressman, I have a question: What are we going to do with dental?” and they say “Oh, no, actually, we forgot about that.” You know, like, yeah, I guess we have to figure that out. I don't think a lot of people know that this letter was sent out with the top 10 professions that PPE had and they were going to get the first crack at PPE in the United States. Dentistry wasn't even in the top 10. It barely made the top 15. It [dentistry] was number 14. Chiropractors, veterinarians, those are just a couple that in my head were put in front of us. Now we're number four. We finally got to number four. But we got to number four, because we had to have a seat at the table and start screaming and yelling. And thank goodness for again, the five congressmen that we have.

Dr. Hartlieb: Well, thank goodness. And thank goodness to people like you, who got up and started beating down doors and making sure that people heard the call. Because we need to have representation. And many of us believe that's what the ADA is supposed to be doing for us. And that's where our dues are going. And it's important that we do have the seat at the table.

I can say thank you because we are essential, and anyone who practices dentistry and our patients know dentists are essential, and you've had the same experience that I have. I am sure that your patients were also flabbergasted that we were closed and that we were not considered essential. So thank you for being part of that to make sure that we are we're looked at as a profession that we are hearing that we take care of people and that we're caring for these people, we're making sure they're healthy to help minimize their risk, because of all times, we need our patients to be healthy. Now is one of those times, because we do know that systemic diseases are influenced by the oral cavity. And we have to make sure that our patients are as healthy as they can be and the oral care is absolutely paramount to that. So thank you very, very much.

We're going to talk about your DSO stuff in a bit. I do. But, I always like to ask this question, as I'm talking to dentists. Tell me, what was your first dental procedure that you remember doing?

Dr. AJ Aciermo: I was doing a DO on a kid that was six years old. First dental procedure, no joke, and he bit down on my finger. And it was about the worst pain that I ever went through. And I'm like, how did I get myself involved in this? No joke. He was the worst in the world. He bit down on my finger. We finally got him off my finger. And then he sat in a corner and refused to get up from the corner. Yeah, it was a disaster. Welcome to dentistry.

Dr. Hartlieb: I like bringing that up. Because I've had the opportunity to be part of Marquette Dental School for 25 years or so. And dentistry has changed for sure. But treating patients is still the same thing that I went through 30 some years ago. And you, a little, more recently than that, but this demonstrats that people biting you is part of the dental experience.

So AJ, when my goal is for young dentists to understand sort of your path and stuff like that. Now you're the CEO of a DSO that owns over 30 practices. And I want to say this first before we go any further - so my practice is a boutique practice. It's a high end fee-for-service practice. And while it's different than many of the practices that are part of your DSO, maybe different than all them in some respects, but we do have commonalities. We have commonalities in the practice, in that we are serving our patients. And a lot of people in my social dental circle think that people who are who own these DSOs, they're sort of like the Antichrist. Is this something you’ve heard?

Dr. AJ Aciermo: Oh, yes. Yeah.

Dr. Hartlieb: Yeah, I take the opposite opinion, quite honestly, I believe that there needs to be service for all patients. And there's going to be patients that have many different needs. And I believe also, not only do patients have many different needs, I think dentists also have many different needs. When I graduated dental school in 1988, Sears Dental had just first started opening their dental clinics. So that was right around, I think ‘88. So the idea of working for a corporation back in the ‘80s, as a dentist was really outside the norm, way outside the norm. But as we've learned, there's a place for this not only for the patient community, but for the dental community. Because the DSO, when it's run well, offers the opportunity for young dentist or even experienced dentist to have a place at the table in a dental practice that will help them in many ways, help them manage their practice, help them manage their overhead, give them a sense of community, give them leadership training-- all sorts of things like that.

So, while many of my colleagues will sort of poo-poo these DSOs, I believe the DSOs serve the dental community really, really well. And especially one of the ones that I like our DSOs, like yours, ones that are really interested in serving the dentist and serving the community and serving the patients. So I want to make sure that we've had that conversation because I'm very, yeah, I respect very much what you've done, and in whole, I believe DSOs are there for a reason. And I don't think it's just a bunch of money grabbers. I think that there is an opportunity to help dentistry overall. And I don't think this is in general practice like mine are going away. I think there's room for both.

Dr. AJ Aciermo: I love having those conversations because I'm gonna agree with you. I think there is room for both. You know, I have a unique perspective because I started out my with a large DSO.

Dr. Hartlieb: Can you say who it is?

Dr. AJ Aciermo: Heartland Dental, and I like them a lot. I'm still friends with Rick and their group. I just kind of burnt out. There's a lot of things I liked and a lot of things I didn't like, you know.

Dr. Hartlieb: Let's talk about that before you before you go on. Yeah. So you're right out of dental school right out of Creighton...

Dr. AJ Aciermo: Right out of dental school. All right. My dad's a CPA. My mom's a teacher. My brother took over our childhood dentist’s practice. So I had no where to go.

Dr. Hartlieb: All right. So you're working for Heartland Dental. And you said there's things you liked about it and things you didn't like? So as a young dentist, a couple years out, what did you like about it? What was the good of your experience with Heartland?

Dr. AJ Aciermo: The amount of training I received my first two years. I couldn't match it anywhere else. I learned how to run a business. I learned how to do better root canals. I mean, they put me through so much CE. In fact, I'll tell you how much - 340 hours of CE in the first year.

Dr. Hartlieb: Wow.

Dr. AJ Aciermo: That's how much I went through. I actually spent more time on weekends doing CE than I did hanging out with my friends my first year. Now they've learned from that because I think there's a negative to that - you get burned out, you know? I mean, all of a sudden, like you're a year out, and you're burnt. They've learned from that.

But there's some things that I like, and I don't like. The other thing I didn't like is that, you know, when you're part of a big corporation, just being a number, you know, all of a sudden, everything starts to be cookie cutter. All of a sudden, all dentists are the same. You know, those things I didn't like.

But I was able to go from that to private practice, a small private practice, to where I brought three other dentists in my building's offices to make a large dental practice. Now I'm a private dentist in a large dental practice.

Dr. Hartlieb: And is this a general dentist correct?

Dr. AJ Aciermo: That's the practice in Schaumburg.

Dr. Hartlieb: So AJ took over a practice from a senior dentist who retired in the community where I was part of a study club. And that's when AJ and I first got to know each other.

Dr. AJ Aciermo: And then I tried growing that one. And then I started doing some consulting for about a year and a half. And then some of the people that we helped out, were like, “Wait a second, why don't you use my practice?” And that's when my mind started moving and saying, “Man, the one thing I liked about the DSO, I can't get in private practice. But the things I didn't like, I like about private practice. So how do I merge a company with all those things?”.

In fact, that picture right here behind my wall right here is the first drawing of what we imagined a newly formed type of DSO and that model would go through. So we wrote it all down, and the rest is kind of... my brother and I had a vision.

My practice was a pure fee-for-service. My brother's office was a pure PPO office. And my dad came to me one time and he's like, “Man, your brother's a good dentist, but he's not doing what you're doing. What is it?” And I'm like, “Well, I'm fee-for-service. He's PPO.”

But once we got into my brother's office, and was able to make changes, and bring him from a $500,000 office to a $2 million dollar office, in about a 14 month period, he was able to see “Oh, my gosh, I was missing, not the actual dentistry. It was more dentistry walking out the door than walking in the door.” Okay, so it's trying to figure that out.

Dr. Hartlieb: So, I want to do a deep dive into this. First, I want to talk about when you talk about taking over Jack's practice. So when you come from the DSO world and now you're going into a private practice. Now you own a private practice. What skill set did you get from the DSO that immediately felt like it helped change the organization or change that practice that allowed you to grow their practice? I'm assuming that you grew that practice, once you took over their practice.

Dr. AJ Aciermo: I could tell you in a minute of what I had to do is print out one report out of their out of their computer system. And I could tell you like that, what they were missing.   The X-ray program wasn't being run. Perio program wasn't being run. The patient's acceptance was very low.

Dr. Hartlieb: All right, so what do you do? Let's go through those three things for our young dentists who are watching and listening to this. So you're looking at the perio, you're looking at a peer report--what percent of patients are having pro fees versus what percent of patients are having scalar root planing?

Dr. AJ Aciermo: S
o let me back that up for one second, before we get into that, Dennis. For all young dentists, for reasons that nobody has ever been able to prove, a successful dental excels at these four foundations: That's customer service, recall, treatment presentation, and accounts receivable. If you can't do one of those four, well, you're probably going to find yourself in a state of chaos.

Next, we're relationship based business, right? If you can't form relationships with patients, because I will tell you, I've seen the shittiest of shitty dentists, with the most unbelievably successful practices. They're dynamic individuals. And I have seen the best dentist in the world with the worst practices because they're just not dynamic. And they can't connect with anybody.

That's why customer service is always first. But the second thing that everybody should realize is this when you're looking at dental practices: 120 adult prophies per month 120, adult prophies, no perio maintenance, just adult prophies If you look into practice, and you see 120 adult prophies, you know that that practice can do a million dollars a year without being aggressive. If you see 150 adult prophies you could do between 1.2 and 1.5 million. If you move to 180, you could do 1.5-2 million. If you're over 200, you'd probably need another dentist in there. And you could do over $2-2.5 million. Usually. So there it is, and it works like clockwork, it works like clockwork. So when you ask me, what did I learn? That's the report. So I just started looking at all that stuff and trying to figure out, wait a second, where am I at right now? And how can I make this work?

Dr. Hartlieb: Okay, so let's say you go to this practice and say there are 120 prophies per month, but they're only producing, say $600,000 a year. So what are you looking at? That says, well, where are we off?

So there's the patients in the practice, you get 120 properties a month. So you got the patients in the practice? The dentist seems like a nice person, they seem like they can engage and stuff. What are you looking at? What's the next step?

Dr. AJ Aciermo: Looking at where the shortfalls are. Okay, so I'm going to tell you where most dental practices are. Actually I'm going to get to your question, but I got to state this first, right? Whenever somebody comes to me and says, “Man, I got a problem with DSOs.” My answer is, “I have probably the same problems you have. There are bad actors in every field, for sure, right? Yes,”. I tell them though,” But if you really want to find bad actors, come hang out with me.”

I look at 20 to 30 dental practices per month. Post pandemic, I'm looking at 60, but 20 to 30 pre-pandemic. When you walk into these offices, you will be stunned at what you see. So for example, 30 new patients a month, all year long. 30 new patients a month, zero quads of scaling and root planning… interesting. That's odd, right? No full mouth x-rays ever taken in the office? Um, it's prehistoric, like, it's, it's crazy dentistry. Right? Nothing that even remotely looks like the standard of care. And the unfortunate part is that I see. I'm gonna be totally honest, this is a straightforward answer. And I will say this, anybody, and I and I actually encourage people to come and see it for themselves.

Unfortunately, 70% to 75% of the practices that I look at, and it's not just because I'm looking at crappy practices, just a random guess has that issue in it. So when I'm looking at these practices, I'm finding a $600,000 practice that sees 120 prophies. They don't have an X-ray policy. They don't have a perio policy. They are drilling and filling, massive, huge bricks of composite. There's hardly any restorative work that's long term restorative work. It's all short term restorative work. There's not one perio chart done. These are just things that are occurring in there that you're like, Oh, my golly, this is mind boggling.

Dr. Hartlieb: So if you take over a practice like that this may be veering a little bit, how do you know how to not lose the patient base? And how do you...and I know it's going to take a lot of retraining for the team members, but I assume that that's gonna be one of the challenges. Also now you're going to be train team members, who for 20 years have been told they don't need to take full mouth series of x-rays, they can just take pieces here and there. So how do you make that transition from taking a practice that is doing not standard-of-care dentistry? And, and challenging the practice to do standard-of-care dentistry, which is not only good for the dental practice, but appropriate for the patient as well? How do you handle that?

Dr. AJ Aciermo: Yeah, no doubt, it's the secret sauce, right?

I will tell you this. We have at Decision One, retention of old team members, that is team members that we have gone ahead and acquired in an office - this is over 70 transactions, because there've been a lot of transactions that we've molded into the 31 practices that we've had, okay.

So we have well over 70 transactions, 94% retention of team members, and we have approximately 91 to 92% retention of patients. So that's our benchmark, our benchmark actually, is we want 94% retention of our patients, in some cases, like we're talking about right here. And the worst case scenario, it's a $600,000 practice disaster, we hope that we retain about 84 or 85% of the patients that are coming through there.

You just gotta start teaching, and you got to understand “The Why”. That's it. And what we do differently a little bit is that our clinicians talk to a clinician, it's only doctors talking to doctors, there's no non-doctors talking to non-doctor or doctors and, and all that stuff with it is church and state, we make sure that our clinical state, and that they are talking with our hygienist and doctors.

Dr. Hartlieb: They don’t have someone coming in in a suit and tie who's just some numbers and metrics person coming into town about how they should be running their practice? You're saying look, “We're peers, I'm a dentist, you're a dentist. This is how this is how we were taught. That's how we're trained. This is why we're taught this we're trained.”

Let's get you back how you know that you're supposed to be doing it. Is that sort of the conversation?

Dr. AJ Aciermo: Absolutely. Now, I will tell you this even on the Heartlands and the Pacific Dental Services and everybody that's like oh my god, those are the prime suspect number ones right that that you were talking about earlier. I will be totally honest with you. I have never heard - I have never witnessed myself personally when I worked there - anybody telling me how to do dentistry. They try to improve my business? Yes, that is an absolute dagger to the community of dentistry and any DSO person will tell you, nobody should be telling a doc… it is a support organization.

A DSO is a dental support organization, you're supporting the dentist, you're not on the business side, you're not supporting them and telling them what to do on the dental side. They have their degree, you should know what they're doing now. Okay, do we mentor? Do we try to mentor and help them through that? Yeah, absolutely. Just as if you were a dentists mentor, one of your associates, right. And in private practice, that's what we do at least in our DSO. And we really make that happen.

The other thing we do is we teach our offices, which a lot of people disagree with us on, but we teach our officers how to fish. We don't fish for them. So I will teach them how to read numbers. I will teach them how to self-diagnose the issues in their office because nobody wants somebody in a suit to come in and tell them that they're doing something wrong. We want them to figure it out themselves. So we don't have to do that. We want to support them saying, “Hey, I got a problem here. You got one other practice, tell me what they're doing right?” so we can fix it. That's what we want them to do. We don't want them to fail either. So does it occur? Sometimes we're there. They don't realize that something bad is going on and that they are not getting good acceptance. And then you have to say, “Hey, let's wake up and smell the coffee here. What do we have going on?”. And it's usually an easy conversation because the doctor doesn't want to be losing patients and doesn't want to be doing any of that stuff.

So, it's kind of the best of both worlds if you hire a consultant. So, I always tell them, “Just look at me like that,” but If I come in and start telling you that you're not diagnosing enough, or you're not doing any of those things, that's how you get your license, right?  Like, if you if you're not doing any perio be comfortable that you're going to get sued. Right, just be comfortable in that. So that's, that's how we go about things.

Dr. Hartlieb: Well, talk a little bit about your DSO, because it's a little bit different, I think, then, as we talked about, with maybe Heartland, or some of the very big DSOs. So you guys have a very different, I think, way of bringing your practices together. So talk about how you guys have brought your practice together and ownership of your practices, and what it means to be part of the Decision One dental group.

Dr. AJ Aciermo: So “taking over a practice” and “partnering with the practice” is, first and foremost, are two different things when you acquire a practice. Okay, we partner with a practice. Taking over a dental practice is usually what DSOs did in the past, right? They just took it over. And they just said, “Hey, this is how we run our DSO, you either like it or not, this is the best way because this is the way we know it. And this is how you're going to do it.”

Dr. Hartlieb: That's what I heard about.

Dr. AJ Aciermo: Yeah, and we partner with a practice. So my job is the best way I can explain that decision. One is when I walk into a dental office, like a beautiful radio playing music, some of these offices, it's an old radio, but the music coming out of it's really nice, right? You look at it and you go, “Hey, Doc, what we do, we have a doctor expectation meeting before we sign any papers, we say Doc, we looked at your practice, we looked at everything, here are the things that we think are really good, and we can't screw up. And here are things that we need to do to improve your practice.” If that doctor does not sign off on that, and is not there, we do not do the deal. Okay. Now, we at decision one have only grown the 31 locations and only have done over 70 deals. I say “only” because people look at me and go “You've been around for a year, man, you should be well over 100, you should be 150 dental practices.” The reason that we are very slow on growth is because of this method.

So I'm telling everybody, the negative about this method that I'm going through is it's very hard to do a lot of acquisitions. Okay, because, like you, because you're more particular about the practices you want to have this partnership, versus just taking over practice, you want to have a understanding with this other dentists, you want to have a partnership, a collaborative partnership, I can build a dental office and buy dental equipment and plug it in anywhere in America, right? I'm buying all their goodwill, I don't care what my accountants say, I buy all their goodwill, I find the relationships that every single person has in that office. But those patients, if I lose the team, and the team's pissed off at me, and they leave, I lose my investment that I just made in that practice.

Okay, so my view is this, I need to get them on board. And I need to get them to understand why I believe what they're doing is right. And I  need to get them on board. These are the things that can really help your practice. Okay, and I got to give them “The Why” and we are not, we are very clear people first, patients and team members first, systems, you got to have systems in your practice to make it run well. And an ethical, profitable business. And this is more than ever out of a pandemic, I told everybody, my job is to make sure that you have a job to come back to that you have security. That you have a job, that's going to get a paycheck. Okay? If we are not an ethical, profitable business, you will no longer have a home to come to. So that's a job that we have to look at. And I get them involved. So one of the other differences that we do is we are fully transparent dentists, every single dollar and every single thing that is done in the practice is given to the team members. They see how much our doctors make, they see how much we spend on everything. Individual hourly pay, we don't do but everything else is transparent.

So if somebody comes up and says, “Hey, Doc, you made a lot of money this month, we want to share in that. That's right, we're sharing in a big bonus program that we have with our team members, because we want to share with them when there's more.” Yeah, but if they say we want it all, then you're not aligned on our values, right then that the values are wrong there. And those are the things we spend a lot of time and energy on, and are really working on the culture of the practice. Practice the why behind certain things that move a practice forward. That's what we spend a lot of time on.

Dr. Hartlieb: So when you say the why of it, so this coming from Simon Sinek’s “Start with Why” is this the correct?

Dr. AJ Aciermo: Yep. So we train for that.

Dr. Hartlieb: So our young dentists here, who are, let's say they've been in a DSO, like many young dentists do, they'll come out and they'll spend, you know, a few years, maybe five years into DSO, now they want to get their own practice, they want to have ownership. What would you suggest to them when they're looking at a practice? It sounds to me like AJ, like the first thing, if they take over practice, they really have to invest their time and try to manage, let me say that manage the relationships of the team members that are already there. Try as you said, it's all about the people, the patients, and those people are the conduit to the patients.  If you're a new dentist, or the existing team members who are now going to be the conduit to those patients. So for the young dentist, you say the key for them is to work with the existing team members so that they can then help with that transition into the new into the new ownership.

Dr. AJ Aciermo: So here's my first and foremost in regards to associate chips, right. So you come out of a DSO and now you go into an associateship…

Dr. Hartlieb: I want to practice, but let's say you want to buy a practice.

Dr. AJ Aciermo: I would say that the first and foremost, making sure that you have the team, you have the team on board with you, to help you transition to practice is a must. You lose the team, you can lose the practice.

And then I would say for anybody that is concerned, like you hear these bad things, or bad dentists, that are unhappy with a DSO. Right? This is the greatest thing, by the way, any new dentists coming out, you have way more options than I had; you can join a small group, you can join a private practice, you can join a large DSO, I mean, everybody has something that you can offer that offer something for you. And I think that's great for dentistry. But I don't think it's fair when somebody says, “Man, there's a lot of people that have bad experiences at a DSO”. Because I can tell you, because I'm interviewing all our doctors that come in here, I can tell you that there are many people that are having bad experiences in associateships, as they are at DSOs. Right? And it's just because maybe you're not placed in the right place. So making sure that you really do your due diligence: Is this the place for me, especially when buying a practice? You know, the first and foremost thing when you buy a practice is you want to make sure that there's enough patience for you. Right? Especially if you're transitioning. If the doctor says, Hey, listen, I'm gonna hang out for a couple of years. “Oh my gosh, Doc, that's awesome. That means people will love me.” That's terrific. By the second month, you're going to go, why are they doing all the work and I'm not doing any and I'm not gonna make any money if that person is still here.

Dr. Hartlieb: That's a common mistake is when a senior dentist brings in a young dentist, there's enough dentistry for the senior dentist but not enough dentistry for both.

And it's a real issue for this young dentist. That's especially if they've invested into the practice.

Dr. AJ Aciermo: I can probably say honestly, my whole career helping out let's say, call it well over 100 dentists, private practice dentists. And they've come to me and said, “I'm trying to get an associate. Can you help me out?” Yeah, no problem. Let me see. Can you just tell me how many adult prophies are coming through your practice? I don't think I can remember two cases. I don't think I can remember other than two cases that I ever looked at a dentist that, you know, it's a good idea that you go ahead and do that. Right? Because the aspect is if you're bringing an associate and you're under 180 prophies, you're going to have to give something up in order to retain an associate. If you're not, you'll have an associate but you won’t retain them. They're only going to be around six months to 12 months.

Dr. Hartlieb: Because they won't have enough dentistry to do.

Dr. AJ Aciermo: It's almost like clockwork dentists. For a dentist in a DSO, if a dentist doesn't make up $200,000 after their second year, it's 50% retention. If they make over $210,000 after their second year, you jump up to almost 90% retention.

Dr. Hartlieb: So when you’re talking to a young dentist, and let's say because I have a bunch of listeners and readers who are actually dental students, and so as they're looking at DSOs, and they're coming out, as you mentioned, they have so many to choose from as far as variety of DSOs and like you said, solo practices, group practices small DSOs, large DSOs. Of course, finding the right fit, I think is a real challenge when you know, when I was a young dentist, we didn't have any options it was just private practice. And back in the 80s, especially in Chicago, there were hardly any private practices looking for dentists. So it was a real challenge. But I don't know if I would have known the right questions to ask. So for young dentists that's looking at a DSO, they're interviewing.

What is a question or two about a DSO that a graduating student or a young dentist? What's a good question or two for them to ask the DSO interviewer about what's going to be happening? Or what should they know? What are two good questions?

Dr. AJ Aciermo: I want to go hang out in a dental office with a new dentist that you just hired. You know, I want to go in there. And I want to, I want to hang out for an entire day. That is a must.

Dr. Hartlieb: So they should make sure that they have an opportunity to be in the practice, where they'll be going or a similar practice.

Dr. AJ Aciermo: Similar practice, what you're trying to find out is like, what's the culture? What's going on there? Because a lot of new dentists where they're trying to go, they're trying to go in there and they're trying to and I tell them this because I teach over at Creighton, their business, some of their business classes.

So I'll tell them I said, “First and foremost, no job in the entire world is perfect. If you walk into a place and it looks like utopia, and everybody's sitting on “cloud-nine”, and it's unicorns and rainbows, get out. Something's wrong, right?” Somebody's got to be there telling you listen, I liked this, but I don't like this. I like this. But I don't like this, right? That's real life. That's real life, okay, real life. So if you can go into the practice that they're going to put you in, man, that'd be ideal. But if you're not, then at least I'm going there to figure out the culture. That's why I tell every senior I said “If you're going right into dentistry, start the beginning of your senior year, every time every chance that you get go, interview, but hang out in these dental practices, start to experience what you want, look at four or five different ones and go from there. And then the answer should be, or another question should be is, okay, so you're putting in a practice? Am I going to be solo? Or am I going to be with somebody? Okay. And what, and what do they want? And if you're going to be solo, what kind of support are you going to give me? Right? And if I'm going to be putting in an office with somebody? Are there two dentists in there right now? And if they are, how much are they making? And what are they? How much? How many procedures are they doing?

If there's one dentist and now they're adding another dentist, I want to know exactly how many patients are, a number, if there's over 180, adult prophies, there's room for you.  If it's under, it's going to be tough, you know? So, asking those types of questions is really important. What kind of CE am I going to get? What kind of training am I going to get? You know, though, all those aspects are super important.

Dr. Hartlieb: Truly these questions about like, making sure that you get in the practice and see what it's like, see what the culture is, like, that's a great thing. And I wouldn't have thought about that. But that's certainly what I would do. If I was going to be going into a private practice, I would want to be there. You know, when we bring people in for interviews, for coming into the practice, we want them to be part of the practice and see what the culture is like, we want to see how they fit into the culture. So I guess that makes perfect sense. I think asking about how many dentists already are there, or their option for mentorship. If this is a dentist that's looking for mentorship, or if it's a dentist who wants to have his own experience and doesn't need, they're not looking for that mentorship, they want to be their own king, then I think those are also really important questions to ask. That's, that's great.

Dr. AJ Aciermo: Yeah. Also, you know, there's fee-for-service. There's PPO, and then there's Medicaid. Right?  Our company does not do any Medicaid. We have out of our 31 practices, we have six of them that are pure fee-for-service. They don't accept any insurance, more boutique types of practices, they are very boutique type of practices. And then you have the rest of our offices that are more like a family practice, you know, pure, you know, PPO type of family practice. So you want to know that stuff, you know, because I'm not saying Medicaid is bad. I think it's fine. But the question is, okay, how do you bill? Right, right, because now, once you're going to practice with Medicaid, the biggest issue with Medicaid is billing. Yeah. So how are you going to make sure that I'm going to be protected if you screw up my billing, right, because the last thing you want to do is get in trouble with state and have fraud, you know?

Dr. Hartlieb: Yes. All right. So now let's switch over and let's say, because there are some senior dentists, people like me who listen to Dental Online Training. So let's say, what are you looking for? Or let me…I'm gonna reverse this. What type of dentist seeks you out? What type of dentist?

Dr. AJ Aciermo: So here at Decision One, we're all over the board, we have the dentist that is like, “Hey, listen, I want to retire in five years.” We’ve had dentists that have come to us and said, “I want to retire in three months.” We have dentists that are in their early 50s that are just like, “I'm done. I'm done.” Like, “It's, it's either you get rid of the business for me and let me do my dentistry, or I'm not going to be able to deal with this anymore.”

And then you have those that have tried to start a practice out and it's just not working. You know, “It's tough road, you know, again. There's not as many new patients as I thought.” The doubt, you know, “I've borrowed so much money.”

So really, all over the board.

This is what I would tell every dentist though, that is 55 and above, right? Start planning your end. The end of your career. And that could be that could be like, “Hey, I want to work until I'm 70.” We have five of those dentists that have told us. They're over 65. And they're like, “I want to continue working.” As long as you do the standard of care, you can continue working, right? But start planning the financial end of your career, right?

There is nobody that above the age of 60 should be working because hey, listen, I have to work. I'm just being honest, because I've seen this as a disaster my entire career. And it actually makes me sad, because you see dentists that are super successful, and they're great. And they're just like, “Hey, I gotta put another five years in, or else I can't retire.” And you're like, what the heck just happened, you know. So you want to be able to plan that, you know, and part of that plan might be, “Hey, give me a lump sum right now and pay for my practice. And I'll work for you as an employee.” They have the opportunity to either sell it outright, they can go ahead and become a partner with us in that individual practice, they can own a piece called a sub DSO model. Or they can take some of the proceeds that they had, and they buy in on the full company level, about almost everybody does that because you know, as you're growing a DSO, and as you get more investors in, the value of the DSO increases tremendously. Sure. And that's where that's where you can get your most return on your dollars.

Dr. Hartlieb: That's interesting. Is that a common thing with DSOs?

Dr. AJ Aciermo: Yeah, becoming all three of those is a little tough. But, you know, one of those is usually where everybody goes.

Dr. Hartlieb: Yeah. Well, I think that's great. And I don't think many people certainly, my colleagues, don't think that many of us know that there is that opportunity to be an owner or part owner of your practice. Even if you were to sell it to a DSO or group like Decision One. Or even to be invested into the bigger part of it. You know, I think the think that's interesting, AJ, the common thought is, is that the maybe this is old school that the corporation would come in, would look to remove the senior dentist, bringing in a younger dentist at a much younger at a much lower wage, and sort of transition the practice and just work on  data metrics to try and make your practice more profitable. Maybe that's how DSOs were running, or maybe that's still how some do run. But your model certainly seems to be more important to make it advantageous for the senior dentist to stick around and be part of it and help continue to grow the organization.

Dr. AJ Aciermo: Yeah. I don't think it's because of a lesser wage. I think I'm being totally honest there. I think the reason some DSOs get rid of the older dentist is because they're a pain-in-the-ass. I'm just being totally, totally, totally straightforward because it's, it's hard to teach an old dog, new tricks, right? So if you go in there and you want to improve the practice, especially when you put a young associate in there. Now you got the old, and you got an associate, right.

So that's why wages, we pay our doctors-- this is a negative about D1, and I don't know about the negative… I think it's just, we want to be fair: I get paid exactly the same as somebody coming out of school. We pay all our doctors the same. The reason we do that is because I know I can produce more, and I could see more patients. So I'm going to make more money than a dentist coming right out of school. Sure, right. But I never wanted, where all the sudden, it was all the dentists got paid differently. You know, I just, we're all colleagues…all the same. We're all producing a lot. If somebody randomly went and saw me and I was a first year going out of school, and they saw a 10 year person, I demand as a dentist, I demand the same level of care. Right? No matter what, right? So that's what we do. And I, you know, I've had this debate with a lot of people on whether that's right, wrong or indifferent. Why don't you do a tiered process? our view is that our doctors are very happy. Our retention rate, our turnover rate on our doctors, is below 5%.

Dr. Hartlieb: That's great. So one question I have when you have this many practices, I suppose even if you have two or three practices, how do you calibrate between the practices? So as you're placing like, okay, post Covid, now there's going to be a whole new PPE protocol. So how do you calibrate? Are you making best decisions from different practices? I know it's, it's got to come from top down. But there's going to be others that are going to have some ideas and some thoughts. So how do you calibrate? And how do you collaborate, collaborate, as you're there, as you have this many practices.

Dr. AJ Aciermo: So, pre COVID and COVID. Then I'll talk post COVID. Pre COVID, our teams get, just like a consultant would give them, they get a full round of metrics and data about their practice.

Pre COVID, we would meet with team leaders and doctors, every other month, and we would discuss those. And then they had the opportunity to say this is the best practice that we're using, right? This is what's going on, this is what we're doing, we're having low acceptance in my office, great, somebody wants to speak on that somebody else speaks on that. And then you train them and you do some things on training, okay. When you have that many practices, though, it starts to play out to where, you know, just in instinctively, you know, what a practice should be doing, by the numbers of patients that they're that they're seeing, right, or you just know, you just know that and by the way, you see that, in fact that if somebody hands me a data sheet on a on a practice, I could tell you, within the pretty close about what they're probably producing, just by seeing data. So that's what we did pre. Post pandemic, we are doing a lot more, because we always used to meet, right?

Dr. Hartlieb: I’ve been in your meetings when you guys would meet.

Dr. AJ Aciermo: So now we're doing Zoom. And now we're doing weekly Friday meetings, where  a lot of team members are joining in, and they're learning and they're discussing, and they're giving their - “Hey, I'm having a hard time with this,” and “I'm rescheduling this like.” We're in it. And then during the pandemic, every morning,, when everybody was on furlough, we got over 200 team members to join a virtual zoom call. And we would talk about what's going on in COVID what we're doing as a company, but also personally, how can we help each other through this process? So we do now post COVID, we're doing a lot more of this with our teams and making sure that we have conversations with them.

Dr. Hartlieb: That's great. I think that was really valuable for us also, not only with our teams, which we spent a lot of time making sure we were connected with them. But we've actually been doing newsletters, which I hadn't done since I was a young dentist. But every couple weeks we're sending out a newsletter to patients to inform them what we're doing differently, what they should expect, introducing new team members, and I cannot tell you the response we've been getting from patients they are so they have literally said I'm so grateful to get your newsletter. for them. It's like a piece of normalcy in the outside world. And amazing, isn't it? Yep. And as you've experienced again, today, I had someone who said outside of my wife, you're the only other person that I've seen in several months. And so we by bringing our world into them, I think it's given them a little sense of reality, a little sense of normalcy, which I believe patients today are really engaging with. And so no question.

Yep, any listeners out there, and I don't care if you're a dental student, or if you're a dentist, associate or in your own practice, reach out to your patients, and just give them a little heads up what's going on? I tell you, they will appreciate it. And it doesn't have to be a whole lot. We sent out recipes one time, and that was great. You know, and it's been fun for the team. And it's been fun for us. And it's really been, it's been really great hearing back from our patients on how they've enjoyed it. So that's awesome.

AJ, want to finish up? A couple things. I want to ask you, though, before we finish up? This is sort of a corny question. But it's something that I think we have to do as we're talking to young dentists, what's the best part for you about being a dentist.

Dr. AJ Aciermo: Relationships with my patients, hands down. Just the fact that somebody trusts me to treat them. I miss it. Like I still am in the chair two days a week.

By the way, if you're growing a DSO, never stop doing dentistry. Okay? Because dentists make more money than CEOs. And once you become a full time CEO, and you expect to get paid the same as a dentist, bad move, really bad move, because you try to pay yourself too much when you're running this, right. Okay, so. So that's one, there's a bunch of reasons. That's one.

The second reason is staying wet fingered allows you a connection with your doctors, and with your team members. Okay? No, I can't do that forever, as I continue to grow. But that is a valuable thing that you never forget where you came from. Right. And then number three, is probably the one thing that I would tell everybody, when you're a CEO of a company, okay. And you're dealing with making decisions, it's nice to be able to try those decisions in the office when you're working to see if it's actually going to work. So that's just a little something of why I do it. So that's it, but you're in a profession where you're going to make a lot more money than most CEOs out there.

Okay, that's, that's just, that's just the way it goes.

Dr. Hartlieb: I don't think people actually thought that. I would think that most people thought that CEOs actually were going to get paid much more than dentists would be paid.

Dr. AJ Aciermo: if you're working for a half a billion dollar company, or a quarter billion dollar company, yeah. But when you're starting off as a dental organization, if you have 10 practices, just let's call it 10 practices, and your profitability is 2.5 million. And let's say it's worth eight times. I don't mean this is derogatory, you only have a $16 million company. Right now. 16 million is a lot of money. And it's a great company. But it's not enough to pay you what you would get paid at the dentist.

And by the way, if you didn't pay yourself that, then you can't build the support structure around you and get the people that you need around you in order to keep on growing. Right. Yeah. So that's it's always been just business principles, good business principles that you have to look at. But going back, I just missed the relationships. I honestly do. I really do. That's what I am, that's what I miss.

Dr. Hartlieb: Next part, a two part question. First part, what's the most challenging part of being a dentist, not a CEO, but as a practicing dentist, what's the most challenging part?

Dr. AJ Aciermo: People. Yeah, right. Managing people. You know, like, I mean, dentistry is easy, right? Like, you get really good at it. It's fun. Dentistry is easy. It's managing people, personalities, patients personalities. It's that that's what that's what ages you in dentistry fast. No argument.

Dr. Hartlieb: With that. I agree. All right, as a DSO CEO, what's the most challenging thing?

Dr. AJ Aciermo: People. Managing people instead of managing, you know, when I left when I was full time in my practice, before I started the DSO, we had 14 team members in my office. So managing 14 team members and 350 it's just, you know, as a parent, they tell You like, “Bigger kids, bigger problems.” Bigger company and bigger problems.

Dr. Hartlieb: The flipside is having this DSO that's been successful, what's the best part about it?

Dr. AJ Aciermo: The people. Being able to change lives, you know, it has, has really, really made me proud. You know, when you have family members that come up to you and say, “Hey, listen, without this job, we wouldn't be able to do this”, or thank you for allowing us to be able to have these things in life. And that's, man, that's a, that's a great, great place.

The second thing is, I'm happy that we're forming something that's actually improving dentistry. Not making somebody a lot of money, and just leaving dentistry to the wayside. Because running a DSO, by the way you can, you can ramp up, it's going to be harder now after the pandemic, and really, it was starting to get harder, but back when I started my deal, so if I wanted to get really rich, what I should have done was just built up something to 100 offices, make sure that it was okay. and flip it. Right. Which a lot which a lot of dentists did, you know, and they made 40-50 million bucks. Right?

I will always want to build something, you know, our tagline is “We want to make a difference in dentistry.” Yeah, we want to make it like, that's what we want to do. And I still stick to that today.

Dr. Hartlieb: So AJ, your successes with your DSO, what do you attribute it to? Is it hard work? Is it just good old fashioned luck? What's the secret

Dr. AJ Aciermo: Hard work. And surround myself with really good people.

I'm just a dentist. I never took a business course in my life. Right? And I was able to surround myself with people that were a lot smarter than me. I mean, I knew how to run a dental practice.

But there's a difference between running a dental practice and managing banking relationships and legal documents and you know, an 
RCM program and HR department, those are you got to have good people around. You got to have some luck…yeah, you got to have some luck.

I mean, listen, there's some deals that I did in the past that I'm like, “Oh my golly, was I an idiot?” It's the worst move I could have made but man it worked out, you know?” Yeah. And, and it's, it's a lot of work. I mean, people ask me, right. “Oh, AJ, you must be why do you do two days a week dentistry? You must be on ‘easy train’ own your own company, you can do your own hours, you know?”.
And I mean, it's a 60-80 hour a week job. Yep. You know, I mean, when you're when you're running a you know, a $75 million revenue company, all of a sudden you got to sit there and you got to think “Oh my gosh,” like yeah, put some hours in, you know. It doesn’t run itself.

Dr. Hartlieb: Last question. And how do you keep a balance? How do you keep a balance between home life? I know you have a couple kids. Yeah, got a family. You have to practice dentistry. Also I know you like to do other things in your free time. How do you keep a balance?

Dr. AJ Aciermo: I struggle to be honest with you. So working out for me has always been like my release. So right. My kid and my kids go to bed. I have a 13 year old 11 year old and an eight year old. So they go to bed. The 13 year old now stays up but right. You know when they were going to bed and they were really young because remember the company was eight years old so they were really young. It was when they went to bed. I worked out at night.

So I was coming home at 10:30 for my workouts, just that's the time that I could do it. So I came home and I spent time with them. I'm not good at that. I’m being real raw here... I'm not, I'm not good at it. I have a wonderful wife. That is very understanding of it. I'm embarrassed to say that there's probably a good portion of all three of the kids' lives that I miss. Sure, you know, there's, yeah, there's six years, there's six years that I missed, you know, and it makes me sad. But it also, you know, it allows me to show my kids, this is what hard work can get you, you know, yes, you have to, I have to sacrifice a lot of things. But this is where it gets you. And so, I'm not good at it, I'm still working on it, my wife holds me accountable to it.

You know, but when I leave, I try to leave work here. I don't go home and flip computers open. When I go home, I try to be at home and I try to be present. It's really difficult when you run a DSO to be at, you know, because your offices are still open and stuff is happening. So it's hard. But if anybody out there has any really good work on that, let us know. And help me out [laughter].

Dr. Hartlieb: Same here, and I'm trying to execute the same way is to leave it at the office, but running, you know, Dental Online Training and doing dentistry full time. There's limited hours, but also just trying to find that balance. But I'm also trying to do the same thing when I get home, keep the computer closed. And just make sure that I have time for the personal relationships that are important, because that's what it's all about.

Dr. AJ Aciermo:  1:11:27 Yeah. And it is no question about that.

Dr. Hartlieb: AJ, I'm going to put a link to the website. So if anyone wants to connect with you, either they're interested in more about your story, or they're interested in your practices, and they want to sort of come in and maybe partner with you or they're looking to come in and as an associate, we'll make sure that we create that link so that they can do that so they can catch up with you and stuff.

Yeah, I personally cannot thank you enough. I'm truly blessed to be surrounded by people who are so caring, and giving. Because in a world where there's not sometimes a whole lot of it, and there's maybe it's just harder to find it. I've been fortunate to find people who are really open and giving of their time and their information and sharing with our DOT audience. I simply can't thank you enough. I'm truly blessed. And thank you.

Dr. AJ Aciermo: Thank you now and ditto on my part.

Dennis, listen, there are very few people in my life that you meet where you say that, like you've actually changed my view on something, and I'm telling you the dentistry that you do is remarkable. You know, it is remarkable.

Can I give the story before I end this? Alright, so I'm at your office. And I won't say the name. Okay, so a very well-known dentist was in Dennis's office doing some work. And I was like, “Oh my gosh, I gotta see this work.” So I go in there and there's this woman. He's doing some veneers, or some composite veneers, and I mean, he's doing it beautifully. I mean, it's just mesmerizing. And he looks at me. I'm gonna be a little crude here, but I got to give the whole context right? The patient in the chair, right? Yep, he looks at me and he goes, “What's your name? Do you know how fucking lucky you are to watch me do this?” Yep, I am really like, I am lucky. But I'll tell you what, I learned so much from that day. It was awesome. Awesome.  

Dr. Hartlieb: Well, I remember that like it was yesterday. And yes, my former partner he's quite colorful in his language. It's not the only time he ever dropped the f-bomb.

Dr. AJ Aciermo: It was great. But honestly, it's people like you, Dennis, that make dentistry go man, and what you're doing for these young dentists what you're doing for dentists and dentistry. Thank you. Thank you so much.

Dr. Hartlieb: All right, AJ, thanks so much, and I will be talking to you down the road. And to our Dental Online Trainers, thank you for joining us for the Sharecast. And look forward to seeing the printed transcription of this also on the DOT blog site, and we look forward to seeing you at our next ShareCast. So thanks for joining us!

Dennis Hartlieb, DDS, AAACD

DOT Founder

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