The Group Dentistry Now Show: The Voice of the DSO Industry – Episode 10

In this episode, Dr. Craig Saltzman, CEO of Affinity Dental Management, and Amy Cadieux, Integrations Manager at Affinity Dental Management, talk integration and share some of their secrets of success. If you are looking to understand integration for your dental group or DSO, this podcast is for you! They know what they’re doing at Affinity as they were recently added to the INC 5000 list of Fastest Growing Privately Held Companies.

Our podcast series brings you dental support and emerging dental group practice analysis, conversation, trends, news and events. Listen to leaders in the DSO and emerging dental group space talk about their challenges, successes, and the future of group dentistry.

Watch the video interview or choose your favorite listening app below and subscribe today so you don’t miss an episode! Full transcript is also provided below.

 

FULL TRANSCRIPT

Bill Neumann:
I’d like to welcome everybody to the Group Dentistry Now Show. I’m excited to have our guests here today. They are from Affinity Dental Management. We have Amy Cadieux and she is the Integrations Manager at Affinity and the CEO of Affinity Dental Management, Dr. Craig Saltzman. Welcome to the Group Dentistry Now Show.

Craig Saltzman:
Thank you Bill.

Amy Cadieux:
Thank you.

Bill Neumann:
Thanks both of you for being here. I’m going to give you a little bit of a background on both Amy and Dr. Saltzman. Amy is the Integrations Manager. Like I mentioned, she trained on the job as a dental assistant and began working with Dr. Saltzman in 2001 at Western Mass Endodontics. In 2011, Dr. Saltzman expanded his work into mobile 3D imaging to support other dental offices using North Star Mobile Imaging. Amy transitioned to work exclusively for North Star and she was taking CBCT scans and managing all aspects of the mobile company. And at the end of 2016, well that’s when Affinity Dental Management was formed and Amy began working with newly affiliated practices to help them integrate into the larger organization. She is a member of the operation integration department and she works closely with Meredith McGonigal and Meredith was named one of the DSO influencers to watch for 2019 by Group Dentistry Now. Amy, welcome to the show.

Bill Neumann:
Craig is also with us and Craig is the CEO of Affinity. He earned his Doctor of Dental Medicine from Boston University in 1997 and he continued on and became an endodontist. He received that certificate from the University of Buffalo and also his Masters in Oral Science. He then joined Western Mass Endodontics. Craig is passionate about building a network of practices offering general and specialty dental services that are well known for providing superior patient care and service. He also maintains memberships in numerous dental organizations, including the ADA, the American Association of Endodontists, the Massachusetts Dental Society, the Valley District Dental Society, and the Hampshire County Dental Society. Welcome both of you to the Group Dentistry Now Show.

Craig Saltzman:
Thank you.

Amy Cadieux:
Thanks.

Bill Neumann:
So big news this year for Affinity, you were added to the INC 5000 list of Fastest Growing Privately Held Companies. So congratulations there. Why don’t you talk a little bit about the growth of the organization and how you got on the list? How did that all happen?

Craig Saltzman:
Great Bill, thanks. So yeah, that was a real accomplishment. The team really worked hard. Devin, our marketing director, really kind of took the bull by the horns to get that to happen. We were excited about that. Affinity started… I started back in 1999 as an endodontist. I came and started working in one location and my partner and I spent about three years developing a model that we thought we could scale in our market. The vision was just an endodontic platform. We spent about 10 years acquiring and opening endodontic offices throughout the western part of Massachusetts and created Western Mass Endodontics and ran into business.

Craig Saltzman:
We really developed the model of creating a superior patient experience at that time. We didn’t want to have just a dental visit and wanted to be leaders in endodontics and we started hearing from our referring dentists about, can we do implants, can we start taking the teeth out that were fractured when they were in our chairs. And that kind of led us to the natural progression of periodontics and once we’re thinking about bringing those services into our locations, we really wanted to provide full periodontal services.

Craig Saltzman:
So the demographics of the area around Western Mass Endo seemed very similar and we started speaking with colleagues and we decided to start acquiring some perio offices. We had 10 endodontic offices and four perio locations at that time and really had a good network of referring dentists, about 800 referring dentists. And our referring dentists started asking us if we’d be interested in buying some of their practices. And one thing led to another. Being very sensitive, the referral based network, I chose three offices that I was comfortable with and we acquired three general dentistry offices. And June of 2017, Affinity partnered with Mid-Ocean Private Equity Group to really scale the idea of a multi, true multi-specialty platform. And the goal was to really have leaders in the lines of service in all different communities and then have general dentistry sprinkled all around it.

Craig Saltzman:
So we’d have a nucleus of specialty. And then around that nucleus was a network of general dentistry practices. Most of our merger and acquisition is through our referral basis, through our specialty providers per se. So having the leaders in the lines of service, they recommend us to their refers. And that’s how we’ve been able to scale Affinity and make the INC 5000. By the end of 2019, we’ll have about 37 locations, a hundred doctors. We’re very proud of that and we take integration extremely serious. So I thought this would be a great topic to discuss with you and see how this could help other doctors, trying to create a multi location platform as well.

Bill Neumann:
I think this topic is right on, especially for our audience. Whether you’re an emerging group and you’re maybe adding one location or you’re a larger group and you’re adding multiple locations a year. It’s a hot topic. It’s a topic that I think everybody handles a little bit differently. So I’d love to get your take on what integration means to Affinity. So why don’t we start right there.

Craig Saltzman:
Great. So we have an integration team. Amy leads the team and when we sat down and we defined… When you look at the definition of integration, it means bringing people together or uniting people. I think we use a version of that definition. We bring the people and the teams together, what we… Every location, every practice has their own cultural identity. The most important aspect of integration to us, it is calling the nerves of these newly acquired practices because these teams have been working together with their founders 20 years, 30 years. So we take this extremely sensitive, I mean the whole process of integration is emotional. So Amy’s going to get into the detail on how she managed the emotions of the doctors, of the staff and everything that goes on around that. So I think really it’s all about the different teams.

Bill Neumann:
Yeah. I mean certainly you hear about integration, a lot of times you’re thinking the business component, it’s not… You don’t necessarily consider the culture, but like you said, if you don’t have that cultural mesh, you don’t have that comfort. That’s probably even more so important than… Although everything functioning from a business standpoint.

Craig Saltzman:
Yeah, absolutely. I mean there’s quantitative and qualitative analytics and analysis being done by Affinity, pre-close and post and to be honest, I mean the qualitative are the most important, especially in the beginning because the office is not going to be able to function and grow and scale without the team. So the areas that we focus on during the integration process, we break it up by department and we break it up in a timeline of pre close and post and Amy’s going to go through all that. The areas that we focus on during those different aspects of the integration are we have an HR department that comes in and Amy’s going to discuss that with you and how she presents it to the team. We have a accounts payable department, our assistant controller goes in, we have a marketing department, we have a revenue cycle department and all these aspects are gone through and talked to the founders as well as the team, through a very organized plan that Amy’s put together.

Bill Neumann:
That’s great. So you covered some of the key areas you focus on when you integrate practices. Tell me a little bit about the integration process in general. How long does that take from, and maybe it varies, but give us an idea of how long that would take?

Amy Cadieux:
Well, we start it about seven weeks prior. Once the due diligence has been started and with legal, we kind of get a rough date for the closing. So that’s when we have an internal and integration meeting and we bring all the teams together. Like Craig was saying, the HR team, the controller, our marketing, our operations, as well as our revenue cycle. They all come in, we all discuss all the information that we were given to prior and we start breaking it down and we come up with a schedule for everybody to come in at their appropriate time during that integration. Of course we don’t want to inundate the new employees in the new practice with all these people running around. So we try to limit exposure and spread it out a little bit.

Bill Neumann:
Sure. So that actually… The cycle doesn’t seem as long as I might’ve thought it would. Does it vary since you’re truly a multi-specialty DSO? So does it vary, I guess from an endodontic side, are there different stages? Is it longer with specialty? Is it longer with GP? And do you have different ways of handling specialty versus GP?

Craig Saltzman:
You want me to take that?

Amy Cadieux:
Yeah, go ahead.

Craig Saltzman:
So as far as the specialty versus GP1, what I would say is remember the most important thing is the people. So one, when we look at specialty in general practice, one is a referral based business most of the time, and now things are changing in specialty and general dentistry is direct to consumer. Our idea of integration is yes, we want to bring the teams together, but as far as a cultural identity, especially when you look at specialty in general, we want everybody to maintain that. We have a non-branded model and we spend a lot of time pre-close during that diligence phase, understanding the cultural identities of the business. So as far as our integration process timeline, there’s no difference. We’re all about the teams and the staffs and the people.

Craig Saltzman:
As far as the businesses themselves, we want to definitely make sure that the amount of time these founders have spent in building a reputation for their businesses and the way they’ve done it, if we’re investing in them, we obviously love their culture. I just want to touch on one thing you said. Just seven weeks is not the completion of the integration. The seven weeks is really the foundation of the integration because Amy’s going to get into some of the key topics that are completed at the end of those seven weeks to let you know really my thought is it takes one full year of a practice integrated with Affinity to really understanding it, everybody kind of moving in the right direction as far as scale and growth. And we are very detailed and deliberate in that process. Because, like Amy said, we don’t want to disrupt the business in a way that the businesses can continue to flow by bringing all these new ideas. So based on Amy’s assessment, which she’ll get into, we create a plan.

Bill Neumann:
Okay. So I know Craig, you mentioned some of the key areas. Maybe we could break the key areas down a little bit and then also then talk a little bit about the different stages of integrations. So I don’t know who wants to take that, but let’s talk about key areas. There you go, Amy will take that. And then of course the different stages because that’s super important.

Amy Cadieux:
Yeah, so we have about three stages. It’s the pre, the closing, and then the post-close and the pre-close again starts about three weeks prior to closing. And we again, get together with our internal team and we discuss with the information that we have. We then start the HR process and that’s where myself and the HR team, we start going through every employee’s information that we have. We do during that time make an employee folder for them with their private information pertaining to them and just details about us as well. So they have that information.

Amy Cadieux:
We meet with Meredith, our VP of Ops, and we discuss this OR chart for the practice, who does what and where can we integrate them along the way into different maybe roles and use them, as well as helping us with the integration with the staff. If they have a good foundation with the staff, we want them to help us. So we do that. We also meet with the doctors, the founder doctors about two weeks out to closing and it’s myself, it’s Craig and it’s Meredith, and we like to just get a little bit of an idea from them personally what we’re looking at with their employees, what they think we should know upon getting in there and also so that Craig can discuss with them the message.

Craig Saltzman:
So we take this… Listen, this is a very emotional time for the founders. I would start with that, but this is their baby. This is what they spent their whole life building. So we… I being a dentist, going through this process, this is something that makes Affinity unique. I went through exactly what they’re going through emotionally, understand how sensitive and heightened everything is. So we sit down two weeks out with the founders over a casual dinner to hear from them how they want the message to go to the team on the day of the close. This is really important to them. We’ve had some doctors, we had one, just some variants. We had one doctor that at close he dressed up as Mickey and took his whole team to Disney World and announced that he sold the business.

Craig Saltzman:
That’s definitely one extreme. Most of the doctors, we go to dinner, they take staff and we view it. It’s not, I sold my practice and now I’m finished taking over. We really form a partnership, okay? And we’re here to support the founders, whatever line of service, whether it’s general dentistry to ortho, whatever it is, to kind of help them, their business too with synergies, mostly administratively, and how they can grow and give them the support they need. So that’s really what we do a lot of it pre-close. Amy spends a lot of time with HR to really make sure that the employees and the team that’s going to be joining the Affinity family, as clear a statement and mission and understands that their roles, there might be some alleviation to some of their responsibilities. That’s why we create this OR chart, so that we can analyze some of the different components of what an office manager or what this front desk coordinator does prior to close and what we may be able to do to support them in a different way post-close.

Craig Saltzman:
So we really spend a lot of time learning about the DNA of the office prior to close so that when we get into the closing, the announcement happens in then Amy starts her whole integration timeline in different phases. We’re not surprised and neither are the founders. Transparency is the number one thing right now at this stage of the game in the process of the acquisition timeline. The doctors need to feel fully transparent. We’ve already got through all the quantitative analysis and the Q of E and all the numbers are done and now we’re just learning how we’re going to work together.

Bill Neumann:
Okay.

Craig Saltzman:
So then you want to do the close I guess?

Amy Cadieux:
Yeah.

Craig Saltzman:
Yeah.

Amy Cadieux:
So no, all that’s happened, all that’s taken place behind the scenes. Now it’s the day of the announcement. We make our announcement, we meet with the individual employees at… As they want to. We discuss things that they want to bring up right then and there. Otherwise, after the day of the announcement, that’s when things start to roll out. That’s when employees start to really I think, notice and feel what has happened and we go through a process with them. We have, again, the HR department will come in usually a few days after we’ve closed. By then, all these employees that have had the initial questions that have come up, they then address them with the HR department, help them enroll in benefits, onboard to ADP for payroll, all that information that maybe they didn’t have before. We then also have our controller come in and meet with the managers or manager and just go over her processes that she expects and explains to them what we need from them on their end.

Amy Cadieux:
We have our revenue cycle management department. Somebody from that team comes in and just, it’s all numbers the first week and IT comes in, our partnering vendors come in, kind of does an analysis and that’s kind of done behind the scenes. We don’t really want to interrupt any employees or day to day business when we do that. It’s quiet. And as this is going on, because I’m there about roughly four weeks on physical site with all the employees. So throughout this time I’m really getting a good idea of what’s going on in the office department wise, employee wise.

Amy Cadieux:
And then I create an assessment and that brings us to the post part of the closing of the integration plan. Once I dropped the assessment, we sit down with the admin team, the operations team and we discuss it and we find out if there’s ways that we can actually improve anything. Can we assist them with anything, in anything that they need help with? Our marketing director comes in, she kind of gets a good sense of the culture that’s going on around the practice, inside the practice so that she can kind of help them with that.

Craig Saltzman:
And then at the end, then what happens is that’s really the initial part of the integration. But Amy, when we talk about seven weeks, Amy’s three weeks prior, four weeks onsite. So that’s how we define integration. Now once the assessment’s completed, then there’s a lot of follow-up with our operations manager and a plan, right? The goal is to really get everybody to feel comfortable at the end of the seven weeks. The team is comfortable, because during this whole process that she just kind of briefly outlined, she’s really spending a lot of time with the team members. They hear the announcement and everything sounds very much overwhelming and they… We have to constantly reinforce them. Amy spends a lot of time there, four weeks, constantly reinforcing the team and understanding the business. She’s assessing the systems that they have in place. So that we could see what we can do to help strategize to scale the businesses. But, really that’s not the completion of integration, it’s just really the start, because now we have our assessment, we put a plan into effect.

Bill Neumann:
Sure. So for four weeks onsite, yeah. So you get… So a lot of it is valuating the business, but it’s also trying to keep the emotions at bay or level. And so yeah, that must be challenging to say the least. Four weeks is a long time.

Amy Cadieux:
Hugging, cuddle time, that’s what I like to call it.

Bill Neumann:
So is this a system that you created on your own? Has it been through trial and error or how did you get to three weeks? Pre and then four weeks onsite. Is that something you’ve kind of figured out ahead of time?

Amy Cadieux:
I think with some of the initial integration-

Craig Saltzman:
Acquisitions.

Amy Cadieux:
Acquisitions we’ve had, it just kind of started realizing we need this information prior to going more educated. So that’s where it’s come from. And it just, again, every acquisition I’m learning something new and I think I really need to know that or I could do this better. We could do this better. So it’s forever changing.

Craig Saltzman:
Yeah. And the key component of… We developed a plan through multiple, multiple acquisitions. I mean, I started acquiring endodontic offices in 2002 so that was the foundation. Now how do we bridge that to where we are, just through trial and error and learning. But the key is whatever we’re doing, we’re not disrupting the business. And the key is we’re not doing anything to enhance the emotional nerves that are going on. We want to call everybody. So if they start seeing new faces, they might be like, “Whoa, Whoa, Whoa. What are all these new people doing?”

Craig Saltzman:
So it’s not like these people are kind of just going through the door. It’s four weeks and every week Amy has something laid out and it’s, we have benefits come in and do some lunch and learns. We do a lot of different things to try to make the team relax. We have a lot of staff meetings and lunches onsite. So Amy can kind of… They get to see Amy and we try to take some of the business out of it. We want the team to start to relax because they were really nervous at the meeting and rightfully so. So that’s why when I think of integration, I just think of emotion and I think our… Amy’s job really, is to control the emotions of the teams.

Bill Neumann:
So you almost answered the next question. So we talk about making the process of easier for affiliating practices. So that integration process, you talked about HR coming in, doing lunch and learns. Anything else that you do really to kind of ease things for the affiliating practices?

Amy Cadieux:
Yeah, a lot of one on one time with the employees. I’m accessible to them at any time, even after business hours, if they want to call me, email me, whatever. I spent a lot of again, time individually with these new employees, just ensuring them that we want them. And what we saw in the practice wasn’t just the doctors, that we saw them as well because they’re a part of the team.

Craig Saltzman:
And that’s our message, right? It’s a dental family. We want that. And we understand that we want them now to join our family. And we understand that the culture that we’re investing in is, is not just because of the clinical doctors, it’s the entire, it’s the clinical staff and it’s their administrative staff. And our job is to kind of leverage our… And synergize our systems to help them. And we know, and Amy does this very well, I mean everybody knows when by the time Amy’s leaves after seven weeks, that they know how important they are as a team member to Affinity.

Bill Neumann:
Well that’s great. Sounds like you’ve really fine tuned the integration process. So I have one last question. Two parts. So why don’t we start with the challenges first and then we’ll end on the successes. So it doesn’t necessarily have to be specific, but as far as challenges go, and it can be specific if you want it. Tell me, tell the audience about some of the challenges that you encounter or have encountered when it comes to integration.

Amy Cadieux:
Challenges? I think really the biggest challenge I’ve come up with is just people being so afraid of the change that they can’t see anything beyond that feeling, that emotion that they’re having. So again, I just work really hard to get them to understand that there’s more to it. Let’s get through this, let’s just continue to work with us. We don’t want you to go anywhere. See what we can do for you, see where it’s not going to be much of a change for you except for the background noise.

Craig Saltzman:
So you’re like… Amy’s like an emotional coach.

Bill Neumann:
Yeah, it certainly sounds that way.

Amy Cadieux:
But yeah, so that’s I think really the biggest challenge is just emotions and just ensuring people that we’re not… We want them, they’re part of the team. We’re team players. We want to be there for them really. And, and I believe that our team at Affinity Dental Management also backs that up. So any time they have an HR question, they can call the department, they’re going to get somebody who is interested and cares about what they’re saying. And that’s all around with all of our team members.

Craig Saltzman:
And in their folder, right, from the initial announcement they have everybody’s in the administrative department, who you call, everybody’s name and email and-

Amy Cadieux:
Phone numbers.

Craig Saltzman:
…phone numbers so that they know if there’s a problem. And that’s why Amy’s there onsite for four weeks as well to help make the introductions as well and to ease their concerns. So I think we minimize the challenges though quite honestly through the business development team, the personnel team spends a lot of time understanding once the quantitative metrics are done and the finances are out of the way. We spent a lot of time culturally understanding the business. There’s a lot of time spent with the founders and we really are excited to kind of… To get it to close and to get started with them and they feel the same way. So that’s one of our big… What minimizes our challenges is really having that transparency prior to close.

Bill Neumann:
I think that’s great. And I mean it just the amount of time that you spend and like you said, four weeks on site. I mean that’s amazing. So successes. So it sounds like the time spent and the systems that you have in place, the structure that you build out, especially on the emotional side, right? The emotional coaching side, the cultural building side. Tell me a little bit about successes. I mean, do you feel like you have more retention of employees? Do you have a happier and easier transition integration because of the time span and the systems you put in place?

Amy Cadieux:
Absolutely. I completely agree with that. I think spending that time again and just letting them vent emotionally as they need to and just helping them calm their nerves, their fears. And I think this is kind of funny, just getting through that first payroll, maybe even the second payroll, so they can see it’s not changing, you’re good. We’re just again, we just want to be their background noise. We don’t want to really interfere on their day to day process.

Craig Saltzman:
Yeah. I think what shows our success is the minimal staff turnover based on the time and Amy being there onsite for four weeks. I mean the two payroll, four weeks is because of two payrolls. I mean we feel after two payrolls that they feel comfortable because we know number one is pay. Number two is benefits for the team. Once we get through that and they see, wow, that hasn’t changed. We learn things about the business post-close. These employees when they meet with Amy, they might tell us things about the practice, how they think they could do something better. The doctors were just too focused on providing dentistry. That’s where we come in, we love that and we love… They love the idea that wow, we’re going to be able to bring specialty in their office.

Craig Saltzman:
Or now we have a network of, “Oh you have ortho in the business. Oh, this is so many exciting things for the team.” And by bringing everybody together, okay, this is the key to Affinity by using the specialist as the nucleus and the educational resource for these dentists. They’re so excited. We have an Affinity Continuing Education Program, okay, that every quarter, taught by our specialists. We bring in all our general dentists and they have… It’s a CE symposium, we utilize our vendors and we just did an Align one. So our orthodontist with align came in and did a lecture for all our dentists. And when you do that in endo and treatment planning for perio. So the dentist, especially the next generation of dentists, are very excited about joining organizations that can provide them the resources to be able to improve and expand their knowledge in dentistry.

Bill Neumann:
And that’s great. And quite frankly, those are resources that they didn’t have available prior, right? So that’s one of the huge benefits of being part of an organization like yours. I really appreciate the time Amy and Dr. Saltzman today, especially focused on integration and sharing some of your secrets. I think it’s going to help out a lot of the emerging DSOs that listen to this and watch this podcast. So again, thanks. I wish you much success and thank you everybody for watching and listening to the Group Dentistry Now Show.