Episode 130: How To Build & Sell A Thriving Group Practice [featuring Dan King]

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Transcript

PATRICK CASALE: Hey, everyone. You are listening to another episode of the All Things Private Practice podcast. I've got Dan King, who is the founder of Fireside Strategic. He has a pretty unusual background at the intersection of law, psychology, and investing.

He began his career in corporate law at one of the world's largest law firms focusing on mergers and acquisitions. Following a rapidly growing interest in entrepreneurialship, he next moved to Shark Tank show working for the investor's draft contractors, due diligence on deals, and helping the companies grow post-investment, noticed that many companies struggle to grow due to leadership and psychological challenges.

So, this is going to be a really cool conversation today, because Dan, you have expertise that a lot of our viewers do not have and possess.

And I know you work in buying and acquisition right now and helping practices sell. And you and I have had talks and conversations about the cultural implications of that. And I think that's one that gets missed. And I think your experience is so unique that I'm just really excited for you to share with the audience today. So, thanks for being on.

DAN KING: Appreciate that and very much looking forward to share it.

PATRICK CASALE: So, tell us a little bit about who you are, because I don't think I did your bio justice in general.

DAN KING: So, I, as the bio says, I sit at this strange intersection of law, psychology, and investing. So, I have spent years learning how you buy companies, and how you help investors who fund the buying of those companies get a return on their money. But for me, it's never just been about the money. It's also about people. So, I would never in good conscience get up at a bed and be excited to work if it was all about the money.

And for me growing any business is about creating a virtuous circle where the people and profits grow simultaneously.

And so, I noticed when I was working for one of the investors on Shark Tank, and after deals closed, I would see these companies grow massively. You know, they'd go on air, and they would get exposure to a massive audience, and they would explode overnight.

And that's a good thing, to some extent. But what would happen is a company with 20 employees would all of a sudden have 100. And yeah, there might be a lot of people who want to buy the product. But that doesn't mean that the entrepreneur knows how to lead a team of 100 if they're used to leading a team of 20.

PATRICK CASALE: For sure.

DAN KING: So, you're going to have people problems on your hands. And I found myself more drawn to those than the legal issues that were actually my job to handle. And so, I left law and I went back to school. I studied psychology, especially, organizational psychology. I wanted to understand how is it that you can grow from 20 do 100 employees and not make a complete pig breakfast of it?

And I learned a lot about how do you actually create a culture where the average employee can thrive?

And, you know, years of starting companies after that, I always just was wrestling with that question in my mind. And, you know, I failed at a few different ventures. Also, grew and sold one. And then I came to a point in my career where I thought, you know what? I want to buy companies instead of growing them from scratch, because it's a lot of work to grow from scratch.

PATRICK CASALE: Sure.

DAN KING: And I thought, "Where do I see an opportunity both for me to have a sense of mission, but also, a good business opportunity?"

And I started doing research on mental health and for years have been drawn to mental health issues, grew up around a dinner table with a brain doctor, father, and a mum with a background in psychology. So, mental health has always been kind of a natural fit.

I started to do research, you know, to explore how our mental health practice is doing and the pandemic hit. And I could see that kind of like what I saw on Shark Tank these businesses were growing quickly. But they also didn't know how to handle growth of employees. They didn't know how to meet this demand. You know, most psychology practice owners are business people. They're wonderful people who care, but they're not business people.

And I started to see that some of those same patterns on Shark Tank were occurring in the mental health practice, especially, independent group practice side of the industry. And so, I thought, "Maybe this virtuous circle that I've been longing to create where profits and people work together, maybe that could be created in mental health."

So, I started to do research. And I started to find that there were practice owners all over the country that share this philosophy. And I ended up partnering with a number of them, a number of them became our investors.

And today, Fireside, the company I run is an acquisition firm in mental health, with this focus of boosting people and profits simultaneously. So, that's how I got here.

PATRICK CASALE: Love it. I think it's such a unique journey. And you're so right, I would almost conservatively guess that 98 to 99% of mental health entrepreneurs have very little to no business experience or training.

So, when we're talking about the pandemic, and the need for mental health care, just skyrocketing, and all of a sudden, people are hiring, and adding people to their practices, typically, without like a plan, without strategy, without having an understanding of how do we develop leadership teams? How do we set a culture? How do we create fun? How do we make sure people feel supported?

So, I love the perspective of doing this simultaneously, in terms of both prioritizing people and profit, because I do think that's just my perspective, as you and I have talked a little bit, is that the better you treat your staff, the more supportive you are as a employer, the more likely it is that they are going to see increased profit, but the company is as well.

And then the company can really grow in a way that feels organic, and healthy, and sustainable, instead of a situation where people are constantly turning over, where people don't feel supported, where they feel taken for granted, or exploited.

And ultimately, what ends up happening is the owner then is hiring, and scrambling, and putting out fires constantly, because it's like, we can't retain talent, because we don't prioritize, or we just don't know how to. And we don't know that both can exist. So, I love that perspective.

DAN KING: Thank you. Yeah, and you know, sometimes people say, well, there often are tradeoffs between people in profit. And sometimes I think that's true in the very short term. But like you say, if people don't feel respected, what's going to happen is you're going to try to extract a little bit of short-term profit, and then you're going to struggle to retain people, then they'll leave. And then in the long term, because this is a people-centric business, you will actually experience less revenue, less profitability.

So, sometimes, yeah, there can be a tradeoff in the moment. But if you have a longer-term perspective, there is no tradeoff.

PATRICK CASALE: Love that. And that's the perspective I've tried to take with my business is like, if I can invest in the short term, and my staff in their development, and their training, and the things that they find interesting, the things that they want to pursue, if we can put a little bit more of the profit into the personal development, both professionally and personally.

We have had a group practice this January will be three years, we have had three clinicians leave in three years, and all three of them were to start their own businesses. We have had very little turnover, and we get any tremendous amount of applications. The difference is for those… because I hear this conversation all the time. And I'm sure you do too, to some extent. I have a lot of group practice owners who I do coaching with or who are in my Facebook group, or whatever the case may be, "We can't hire talent. Nobody wants to work. There are no applicants out there."

And that could not be further from the truth. It's just that you have not created a culture that attracts the right type of applicant. And I think that's the difference there.

DAN KING: You're absolutely right. Yes, there is a labor shortage. But you know, what's the appeal debriefings line, "If you build it, they will come." Right? Because so many practice owners aren't thoughtful about culture.

Good talent is looking for a good place to work. And so, if you create that, right? And you can do some good marketing people, understand that that good place exists, then then you're in a good place.

PATRICK CASALE: Yeah, absolutely. And that means intentionality. It also means that the owner has to take a step back and create some infrastructure where they are not doing everything, because that's another thing that a lot of therapists struggle with is like, I've got to do it all, I can't outsource, I can't delegate. Do you see that a lot in some of the conversations that you're having?

DAN KING: 100%, 100%. You know, it's very tempting to, you know, if you're not used to delegating, right? If you haven't developed that skill set, it's hard to build the trust. I've been there as a business owner myself. It's easy to think no one else can do this as well as me.

Usually, that's not true. But even if it is, right? If some of them could do the task 70 or 80% as well as you, and you got to have a hell of an ego to think that that's not possible, right?

PATRICK CASALE: Sure.

DAN KING: Then there's going to be a ton of wasted effort. And by the way, you're not going to be able to show up with trust, right? People need to see that you trust them if you want to really be a leader. You're not going to be able to show up that way if you are thinking at some level that you need to do everything.

So, that kind of trust can be subconsciously experienced by a team that is well led, and you're going to really, really struggle to get there if you don't trust anyone, and you don't experiment with your own threshold of discomfort when it comes to delegation.

PATRICK CASALE: Couldn't have said it better myself. And I agree, like, there may be instances where you could factually say, someone's not going to do this specific thing better than I could maybe, okay? Maybe that's true. But is your time best serve doing that thing when your vision as the CEO, as the owner, as the boss should be focused on how do we create expansion? How do we grow sustainably? How do we create more referral streams? How do we do all of the things that I need to be handling?

I don't need to handle the calls that are coming in despite my conversion rate being close to 100%. My time is not best suited for that role.

So, having the right pieces in place, whether it's administratively, operationally, clinically, and leadership, but ensuring that you're building something that feels like a team and a cohesive culture. I think that's really important.

DAN KING: 100%.

PATRICK CASALE: And what I see happening a lot of the time, right? Is, I want to pivot and switch gears, if you own a practice, shouldn't you be considering this an asset, something that you could develop and potentially sell? Because so many clinicians are saying, "I'm going to have to work in this field until I die? I'm not going to be able to get out from under this. I don't see an exit strategy."

So, can you talk a little bit about that? And how to start putting the pieces in place to create the type of practices that we're talking about?

DAN KING: Yeah, you know, we talk about delegation, we talk about leadership, we're talking about a business beyond ourselves. So many clinicians who have group practices now never intended to create them. I've probably spoken to 30 practice owners in the last couple of months. And I would say a majority never intended to create a group practice.

PATRICK CASALE: I'm one of those people. I never intended.

DAN KING: Yep, exactly, exactly. So, there's a very different mindset required to build a business beyond yourself. And an even bigger, let's say, more visionary mindset to think about one day getting acquired, right?

PATRICK CASALE: Yeah.

DAN KING: It's a very, very strategic kind of business mindset you need. But one of the things about acquisition, maybe that I'll share with folks, that they don't think about is, there's all kinds of reasons to get acquired. And I think it's important, you know, Patrick's been emphasizing intentionality when it comes to culture. Intentionality is so important when it comes to thinking about an acquisition, too.

You want to ask yourself, why might I want to get acquired? And if I want to get acquired, in what way? You could be entirely bought out, you could sell a majority of your practice, right? It doesn't necessarily have to be all of it.

Sometimes I meet practice owners and these are often the ones we like to work with, who don't want to leave entirely. They're not burned out. At some level, they want to remain involved, they know that they're destined to make a big impact in mental health. But they also know, they also have the self-awareness to know, maybe they're not the savviest business person under the sun, or maybe certain aspects of running the business like chasing insurance companies, right? Or, you know, building an employee engagement survey. That just may not be their jam. They know those things need to be done.

And so, instead of getting acquired entirely, one thing you can do is sell some, not all of your practice to an acquirer. This is our preference. We can invest in the practice rather than buy it out entirely.

And partnering together, right? If we find that there are synergies, we find that there are things our team likes to do, and I can share some of the things that we're really good at doing, you want to jettison some of those responsibilities.

Now, one plus one equals three. And maybe instead of selling all of the practice, you sell a majority to us, maybe it's 60%, for example. But you still hold on to 40%.

And if working together the practice can become infinitely more valuable, then it may become time to sell. And your 40%, you know, you could own 100% of something that's worth a million dollars, or in two or three years, you could own 40% of something that's worth $12 billion.

PATRICK CASALE: Right.

DAN KING: Your 40% stake is now going to be worth about 5 million.

PATRICK CASALE: I love that [CROSSTALK 00:14:32]-

DAN KING: And by the way, you've taken some chips off the table, right? We have paid you for that 60%. So, you've diminished your risk, then you've also exposed yourself to more reward down the line.

PATRICK CASALE: And that's such a great perspective that I think, as you just mentioned, goes unchecked or there's not a lot of awareness that that's an option.

Because I think you're right. A lot of folks want to stay involved but they just can't stay involved in the way that they're doing it right now, in the moment, because it's not sustainable. And maybe there are things that they're really good at. And maybe are there are things that, like, continue to pile up when we're like, we do need to implement this, we do need to add this, we do need to be doing this, but I just don't have the capacity. I don't have the energy. I don't have the bandwidth.

And that is where things start to fall through the cracks. And then, ultimately, it just starts to break apart. So, I love that perspective.

DAN KING: Thank you, yeah. No, there's a million ways to skin the cat. You know, if you get a little bit creative, and you think to yourself, "What do I want? What would be my dream for running this business?"

Sometimes we're burned out, we've been working too hard, we haven't delegated enough, we want to escape. There's a part of us that thinks I just want to be done with all of this. But you're where you are for a reason. If you've built a good practice, if you're treating people well, you have skills, you should be proud of those. And it may be that, the best contribution you can make, the best service that you can provide is to remain in your group practice just in a different role.

PATRICK CASALE: Absolutely, yep, creating and continuing to reinforce that culture that you've worked so hard to create.

And for those of you listening who have created these cultures within telehealth practices, it's really remarkable where you can create something where people feel connected, they feel like they have camaraderie, they feel like they have support and teamwork, yet they don't see each other's faces, often, if at all.

And that's kind of how my practice operates. We have half of our folks here in Asheville after them all over. But it feels very much like a well-oiled machine where everyone is on the same page, has the same mission. And that's certainly a thing that can become a reality.

Now you were mentioning things that you all do really well. Tell us about those things, because I think a lot of group practice owners who are listening are probably like, "I need Dan's email address immediately."

DAN KING: So, I'm going to give you three things. So, the first one is going to be financial. The second is going to be about the comprehensiveness of your practice. And the third is going to be about culture.

So, first, you know, our preference is to look for insurance-based practices, not self-pay, and especially, commercial insurance-focused practices.

And that is because, you know, our team has some of the nation's leading experts in the business of mental health. And a number of them are extremely skilled at negotiating with insurance companies. They have very high level of relationships, they understand the business model very deeply, and how some of the largest insurers in the country work.

We often have the capacity to renegotiate health plan pricing in a way that the average practice owner doesn't. When you can renegotiate health plan pricing, you can do incredible things, just incredible things. You can massively increase over the course of 60 to 90 days your practice's revenue. And you can share some of that increase with your clinicians.

And we talk about creating a virtuous circle, right? Where people in profit work together. If your clinicians get paid more, maybe they even see fewer clients, they can provide each client exceptional service. And those clients are going to refer more clients to your practice. And when that happens, now everyone's going to benefit, right?

So, increasing health plan pricing is a real area of specialty for us, particularly, in some states more than others where relationships are stronger. But health plan pricing in general is the first kind of financial piece I'm going to throw into the mix.

Second, on comprehensiveness of practice. So, we're talking purely from a financial perspective, one of the things that limits a lot of practices is that they just do talk therapy. I'm a huge believer in talk therapy, don't get me wrong. But for us mental health is about more than talk therapy. There's so many innovative approaches to getting patients incredible results.

You know, 80% of practices in the US have no way of really measuring results. When you do measure results, things like TMS, things like ketamine, right there. There's all kinds of innovations in mental health that, especially, sometimes in conjunction with talk therapy, or instead of produce incredible results. We've got to be patient-centric, in addition to being clinician-centric.

And one of the great things about some of these other tools beyond talk therapy is that they are higher margins. So, if you get beyond the typical 15, 18, maybe 20% margins that a talk therapy business can get to give you, you can just do so much more, right? You can spend on more cultural things that are going to keep your clinicians happy.

So, this feeling of super tight margins, not great from a business perspective or a people perspective. But when we add in elements to make the practice more comprehensive, whether it's prescribing, whether it's ketamine, whether it's TMS, now, we just have room to breathe. And that benefits everyone, from patients, to clinicians to founders.

PATRICK CASALE: For sure.

DAN KING: So, we're experts in making the strategic decision about for each practice, where does it make sense to go next, right? Because there's many options. And we're experts in finding the right people to help you introduce these new lines of business.

So, we'll help you decide which one makes the most sense. And we can help you implement a new line of business that's going to produce higher margins and better patient results.

The third big thing that I want to share is retention. So, the biggest risk that we always look to mitigate as an acquirer, and probably the biggest risk is a founder, even without us you should look to mitigate is clinicians leaving.

PATRICK CASALE: Yeah.

DAN KING: So, why do clinicians leave? Well, for some of the reasons that Patrick and I have been talking about. But if you really want to nip this in the bud, you've got to understand anonymously how they feel.

And so one of the things I learned when I was studying organizational psychology is how to do really good employee engagement work. And for me, it usually starts with a survey, a scientific survey, when that enables anonymity. You know, you can ask your clinicians how they feel, but are they really going to tell you the truth? Not necessarily, right?

PATRICK CASALE: Probably not.

DAN KING: Probably not. So, if you do things professionally, you can understand what do my clinicians want? Why do they see value in a group practice? You know, Patrick alluded to the fact that he's had three leave. And that's great, over the course of three years, for a practice his size. And they all left in order to start their own practice, right?

And so many smart clinicians are always thinking that decision through. So, we want to get good data on what's going to move the needle in terms of them staying? And employee engagement survey is a great start. And you would not believe how many creative ideas come up, right? That some of your clinicians have that you won't have about what they want.

So, for us, it's really about retention, retention, retention. And until we're able to create that virtuous circle, right? Where clinicians and patients all thrive, that doesn't happen overnight, we need to understand the status quo.

And the truth is, if you have at least 20 clinicians, you probably don't understand the status quo of how they're feeling.

PATRICK CASALE: No. And I'm so glad you named that, specifically, because I think so many people shy away from it. Because they don't want the feedback or they can't handle like, what if it's critical? What if it feels like it's a reflection on my personhood?

I've had so many colleagues who are like, "The feedback has been terrible, the culture feels like it's not a great place, but I'm putting so much of myself into it to make it that way." So, it feels like there's this incongruence or disconnection there.

So, I think that's so important and so vital. One thing that I do that has seemingly worked out really well is I do quarterly one-on-one check ins with every single staff member too, because I have another business, I'm busy, I'm not always involved in the practice. So, I want to make sure like people can come to me, talk to me. But that doesn't mean that they're always going to feel safe enough to share their thoughts.

So, anonymous feedback is really, really important. And I think a lot of people listening tend to shy away from that for a myriad of reasons. And I just cannot emphasize how important it is to have that mechanism in place.

DAN KING: I couldn't agree more.

PATRICK CASALE: So, for those of you who are listening, and you're thinking I either I'm going to be starting a group practice, I have a group practice, it's growing exponentially. And I need to start really thinking this through. I think you all need to be putting some of this wisdom and advice from Dan into place, because your business is an asset.

And I think it's really important to think about how can we mold this into a situation where it's a win-win all around for the clinicians that you employ, for the clients that you support, for you as the owner who has put in a lot of blood, sweat, tears, and equity, and money into something.

So, you really just don't want it to be a situation I've seen so many times where people are like, "I'm just waving the white flag, I'm packing up, I'm going back to solo practice. I'm not doing this anymore." And taking massive losses, too, financially, because it's just didn't work out the way that you had anticipated.

But I will say this, when I'm doing coaching, I always ask people, why do you want to start a group practice? What is your why? If it's simply like, I just want to refer in instead of out, I want to make more money.

And I always ask, "Do you want to be a boss? Do you want to deal with some of the operational, the training, the admin, the HR, all the components that come with it? If the answer's no, I would recommend rethinking or at least having some support staff in place that can handle the things that you just absolutely feel like you do not want to do or do not feel capable of doing.

DAN KING: I think why is such a brilliant question, it's so easy to neglect. And even if you do have a good why do you have the inclination, right? Do you want to deal with admin and HR? And not everyone does, right? You're going to be honest with yourself that at the very beginning, you will be wearing all the hats before you can delegate. You can delegate, right? There's no way around it.

PATRICK CASALE: Totally. Yep, absolutely. When I first started this, a friend of mine had reached out and said, "Hey, would you hire me?" It was, like, in the midst of COVID 2021. And I was like, "Why would I hire you? I teach practice owners how to start their practices all over the world. I'll do it for free." "I just want to work for someone, I want to have teammates, I want to have support. I don't want to do all the marketing. I don't want to deal with the billing etc."

You have to remember that if there's good leadership in place, people oftentimes want to be led off. Also, people just want to do their jobs and go home.

So, if you're listening, and you're like, "Why would someone join a group practice?" I think there are so many reasons, especially, if you've created the culture, especially if you're doing it well. And I think that's really important to remember, when you're thinking about the trajectory of your career and your professional development going forward.

DAN KING: Can I add one thing to the mix?

PATRICK CASALE: Absolutely.

DAN KING: So, beyond professional development, which is a fairly obvious benefit of working in a group practice, you know, you get to share ideas with colleagues, talk about difficult cases, benefits or another, I see this more and more so across the country, so a lot of practices, and sometimes it's legally required, sometimes it isn't, there's a lot of practices that are converting their clinicians from 1099 to W-2.

PATRICK CASALE: Yeah.

DAN KING: And sometimes, you know, you'll get, even though you're responsible for payroll taxes, what can happen is you can incent clinicians to invest fully in your practice. They know that their health insurance is taken care of, they know that, you know they can get that sense of peace and safety, you run the numbers. You may find that while you're responsible for payroll taxes and some benefits, especially, as your practice gets larger, it gets above 30 and 40 clinicians, you may actually net… it may be that threshold moment where people and profits start to fuse together and there isn't a tradeoff. You may find that people give you more hours, and it's a financial benefit to your practice.

PATRICK CASALE: Yeah.

DAN KING: Certainly in the longer term, you know, while you've got to run these numbers, in the longer term, you will find that this sort of mindset is going to really help address your retention issues. And it's a great reason.

I thought of this because Patrick was talking about why would a clinician want to work in a group practice when they can start their own thing, right? But understand that those benefits, you know, if you survey your people, and you find that those benefits would move the needle for them, it's going to be a huge factor. I see this in practices all over the country.

PATRICK CASALE: So spot on. I think if you can offer your employees peace of mind, and security, and they're getting their basic needs met, or they don't have to look outside of the practice to go work an extra job, pull an extra shift, do an extra thing to pay for their health care, to invest in their retirement, it goes such a long way. It goes sometimes further than the amount you're paying someone hourly, because it is just saying like, we've got you. Like, all you have to do is show up and just be yourself, do your job. That's all you have to do. It takes away so much pressure and so much stress of having to exist in a very stressful world. So, yeah, it goes a very long way. So, I'm really happy that you mentioned that.

This has been a cool conversation and I've learned a lot. I hope everyone listening has too. If people want to find you, connect with you, what's the best way to do that?

DAN KING: Yeah. So, you can take a look at our website, www.firesidestrategic.com. F-I-R-E-S-I-D-E S-T-R-A-T-E-G-I-C.com. From time to time I'll post some content on LinkedIn. But really the best way to take a look at what we're up to is the Fireside website.

You can email me at [email protected]. From time to time, you know, even if your practice is small, more than happy to hear from you. And from time to time I'll be happy to chat with you and to take a look at what you're doing and offer a thought or two.

When it comes to acquisitions, you know, we look for practices that have owners, founders that ideally want to stay on board, don't want to leave entirely, but want to partner with a team of people that can help grow their business to the next level. We look for founders that prioritize culture, really, really care about their people. And we look for practices that have profitability. We call it EBITDA of 400 or up.

And, you know, there's various ways, we don't have time now to get into how we calculate that, that's a whole song and dance. But you know, we look for practices that are at a decent sort of level of profitability and have all those other metrics.

And so, if that's you, and you want to talk about acquisition, then, by all means, reach out to me at that email, [email protected].

PATRICK CASALE: Perfect. Thank you for that. And all Dan's information will be in the show notes so you have easy access to his email, his website, and all of the things that he just listed.

Dan, thanks so much for coming on and sharing all this. This has been a really awesome conversation and I really appreciate your time.

DAN KING: I enjoyed it as well. Thanks for having me.

PATRICK CASALE: You're welcome. And to everyone listening to the All Things Private Practice podcast, new episodes are out every single Saturday on all major platforms and YouTube. Like, download, subscribe, and share. Doubt yourself, do it anyway. We'll see you next week.