Hey chiropractors, we're ready for another Modern Chiropractic Marketing Show with Dr. Kevin Christie where we discuss the latest in marketing strategies, contact marketing, direct response marketing and business development with some of the leading experts in the industry.
Kevin: Welcome. This is your host, Dr. Kevin Christie, and today, I've got another episode of the Modern Chiropractic Marketing Show. Today, I've got an interview with Kevin Misenheimer of Progressive Practice Sales. If you recall, at the end of 2018, in December, I had an episode with his wife, Crystal, and they together run Progressive Practice Sales. If you didn't listen to that episode, I highly recommend it. It was a great episode. We've got a part 2, this time with Kevin, and we're going to dive into basically the ins and outs of buying a practice, and does it make sense for you. Why should you buy a practice versus starting your own? Some of the things to look out for. Things to walk away if... We really dive into all of the information you would want to know when potentially buying a practice or even setting up your own practice with the end in mind and having an exit strategy. [0:01:13.6]
So, we dive into that, and it's a really great episode. It brought a lot of good information. Frankly, I'll probably have one of them on again. I think this conversation needs to be happening more often, and I think it's something that serves not only the buyer, the seller, the owner, or the associate, but it really helps the profession because buying a practice can really jumpstart your career and obviously down the road when you go to sell a practice, you want to make sure you have everything lined up and prepared optimally. So, before we dive into that, I've got a couple of things I want to discuss. We do have a CSA retreat coming up in December. That's the Palm Beach retreat. You can find that link at bit.ly/CSAPalmBeachRetreat. We're going to have a great time there. It's got Jeff Langmage, John Morrison, myself, Bobby Mabee. We're going to dive into small groups. We're going to have really actionable workshop-type of information. [0:02:15.0]
We're going to have quite a few chiropractors there but no more than 40. Basically, what we found in Portland, when we did it which was a huge success, was not only that the chiropractors that came got a lot of information out of the presenters but also just getting into the small groups, kind of like I do when I go to Strategic Coach four times a year. Getting into small groups of likeminded individuals and other people going through the same stuff and bouncing around ideas, and we're going to have in December, December 14th and 15th in Palm Beach, nice and warm. So, if you're in the colder climates, this is going to be great for you. We've got activities planned for Saturday night, beach day on Sunday, learning. Saturday morning we'll actually be learning at the beach, and then, we'll have a relaxing beach day. So, check that out. [0:03:00.7]
Also, I want you to look into the Virtual Summit that I am actually collaborating with Motion Palpation Institute. So, it's and MPI Virtual Summit where it's going to be free. It's a 1-day summit. It'll be three clinical presentations and then three business and marketing presentations. We've got everybody from Mark King to Corey Campbell, myself, and Brett Winchester. We're going to be providing as much content as we can to really help you grow. Again, this is going to be free, and the link for that is going to be bit.ly/MPIVirtualSummit. Check that out. You'll basically be able to watch it from your computer, your laptop, your smartphone, your i-Pad, whichever one you want to, and it's going to be a Virtual Summit. [0:04:02.0]
I've done a couple of these in the past that were a huge success. This is the first one I am collaborating on which I'm excited for. That's going to be on October 24th. So, for right now, I want you to mark that on your calendar, go to the link and register, and then you'll get that email that morning that the videos are out and it'll be dripped to you that particular day and you'll get to learn quite a bit of information. I've been fortunate enough to see the videos so far, and they bring a lot of value. This is high value information to help you grow your practice. So, check that out. Without further ado, here is my interview with Kevin Misenheimer of Progressive Practice Sales.
All right, I've got another Kevin on the line. I appreciate his time today. We had his wife, Crystal, on the podcast not that long ago talking about practice sales and buying and things of that nature, and today, we're going to dive deeper into it. So, before we do, Kevin, introduce yourself and your company and let's go from there. [0:05:00.5]
Kevin M: I'm Kevin Misenheimer. I am the founder and CEO, I guess cofounder with my wife Crystal of Progressive Practice Sales.
Kevin: Perfect, so where'd you guys get started?
Kevin M: We started in 2015. We were taking a sabbatical and moved over to Hawaii for a year after selling three practices of our own using multiple brokers, and we really felt that we could do a better job than what was out there in the marketplace, and it was really a perfect marriage of our two skillsets. We love it. I actually don't feel like I work anymore. I feel like it is talk to docs all day.
Kevin: That's not bad. I do that a lot too but still treating patients. I need to get out of it. No, just kidding. So, correct me if I'm wrong, but you're on the buying side of things. Is that correct?
Kevin M: We help buyers buy practice, and we help sellers with their exit strategy and some things. [0:06:06.8]
Kevin: I know your company does both, but you personally, are you more on the buying side?
Kevin M: No, I help, actually my fiduciary responsibility is always to the seller.
Kevin: Okay, perfect. I'm glad we got that squared away.
Kevin M: As a company though, we do offer lots and lots of support for buyers because most of them have no idea how to buy a practice.
Kevin: Yeah, there's a lot of moving parts to it, and there's a lot of confusion, and that's why I'm always excited to have this conversation because I think it's important too, even for the young docs that are maybe just starting their practice, you always want to begin with the end in mind, and so you want to start the process of have a sellable practice from the get go, right?
Kevin M: Absolutely, and I can give people advice on what a sellable practice is and what not to do because some people get to the end of their career only to find out they maybe don't have a whole lot to sell and bank on as part of their retirement. [0:07:09.3]
Kevin: Do you works with docs that necessarily aren't looking to see yet but want to prepare for that down the road?
Kevin M: Yeah, absolutely. I have a lot of conversations early in the process. It's a long sales cycle in general, and I think the best thing that somebody can do is to have the conversation early. We're signing up people today that I may have spoken to initially two years ago. Sometimes you might to do some things to get your practice ready to sell so you can maximize the value.
Kevin: That makes sense. Perfect. I've got a few questions that I wrote out. Sometimes I do this podcast selfishly where I can get some good answers and things like that, but why should someone buy a practice versus starting from scratch?
Kevin M: Well, starting from scratch, in my opinion, and anybody that has been in practice for 20 years would know, but starting from scratch nowadays seems harder than ever before. [0:08:15.3]
So, students are graduating with student loans in excess of $250,000, and people tell me all the time, because we get a lot of failed practices where someone sunk $100,000 or $150,000 into opening the doors on a place and didn't quite make it. So, if you're looking at a growing city or suburb and you need a nice build out, you need a nice website, you need updated EHR, digital x-ray, and those kinds of things. A lot of times by the time somebody gets the doors open on a place like that, they're already over the $100,000 mark. That startup capital is a lot harder capital to get versus if you buy a practice, you need about 10% down. [0:09:09.8]
So, if you look at the math, 10% down, a little over $30,000 on a $300,000 practice, if somebody were to purchase that with an SBA loan with one of our banks, they're going to probably have close to $200,000 of a net profit as soon as they take over as in the other scenario, they've spent $100,000, maybe $150,000, they have zero patients in the door, and then they've got to burn through more capital for marketing until they finally break even. A lot of sleepless nights until you finally start turning a profit and eventually down the road start making a professional income, and that is really a much tougher row to hoe as they say.
Kevin: It makes sense. So, what should they be doing if they are thinking of buying a practice? [0:10:02.4]
Kevin M: You know, I think if you're younger or in any case, I think you should look at lots and lots of practice profiles. I know a lot of docs...I know it was true for me when I graduated, I had never actually seen the profit and loss statements from a chiropractic practice. I knew what people made or what their gross collections were, but I had never seen what the overhead was like, what the payroll was like, and so, one of the steps, I would say, is look at a lot of our practice profiles. They tend to be really thorough. They tend to be over 40 pages long, so you can see three years of profit and loss. You can see what the value of the equipment is. You can see what the cash flow is, and what people are paying their staff, and if you look at a lot of profiles, 10, 20, 30 practice profiles, you have a really good idea what you want and what you don't want and what's a good deal and what is not a good deal as far as a practice. [0:11:05.4]
Kevin: Perfect, and you help you docs with that?
Kevin M: Yeah. If anybody reaches out to us, and they see a clinic they like, they can fill out a nondisclosure agreement and we'll send them as many practice profiles as we like, and so a lot of docs I'll talk to 5 or 10 times before they actually pick the practice that they want to buy.
Kevin: Gotcha.
Kevin M: They'll become educated in a hurry on what's a good deal and what is not a good deal in the marketplace. Another reason I would say to look at purchasing versus starting from scratch, there are a lot of really motivated sellers out there, and there are some great deals relative to the cash flow that you'll generate.
Kevin: So, you'll actually take a doc who's looking to buy but doesn't know where and what practice to buy, but you can match it up with some sellers that are looking to sell their practice and make it a match? [0:12:06.0]
Kevin M: Yeah, I play matchmaker all day long for a living, and I'll get to know a doctor's skillset, techniques they're trained in, geographically where they're willing to look in the country, where they really want to live in the country, and give them advise that way, and a lot of times, there's something in someone's back yard that is a really good deal that I think they ought to look at when they have been struggling to come up with the cash to move their family across the country and get licensed in a different state. Those are really difficult things to do.
Kevin: So, where are some areas that buyers should consider looking for a practice? Are there any areas in particular that are better than others?
Kevin M: I think that it's really obvious that some cities and suburbs are really, really growing, so Texas has a great economy, Florida. The mid-Atlantic is really hot for us. [0:13:07.5]
People seem to be in mass moving from California into lower tax states. So, I look for growth rate and job opportunities in an area. So, if you look at like a Dallas or a Charlotte or Austin, Texas, or Atlanta, those are places I would really look, and the other place that a lot of docs should consider that they don't is if you can look into a smaller town where someone's been in practice for over 20 years, and they are the largest competitor in an area, you can often make some really good cash flow in an area where you don't have to do marketing, you don't have to do spinal screenings every weekend to make it, and you've got 30 or 40 new ones just coming in the door just because of that practice's position in the marketplace.
Kevin: Okay. [0:14:02.0]
Kevin M: So, as people retire from those smaller towns, someone can go in and pay off their student loans in a hurry which I think should be really at the top of everybody's mind given the current environment.
Kevin: So, how about depending on the state's health insurance reimbursement situation. Like for right now, Florida is pretty terrible as far as what Blue Cross, Aetna, Cigna, all pay about $40 to $45 a visit now, where when I started practicing in 2005, it was a lot better. Aetna is like in the $50s. So, do you take that into consideration, or do you just assume that insurance is going to such in the near future anyway and you don't want to base it off that?
Kevin M: Yeah, I do think that the insurance environment is deteriorating in a lot of states. I think there are some outliers. Alaska is very good for insurance. Indiana is incredible. Doctors get paid similar to the Mercedes 80s. They just get paid for what they do. So, there are some states that are good, and then depending on the practice model that someone likes, personal injury is really good... [0:15:12.5]
Kevin: In Florida.
Kevin M: In some states like Florida. Florida, Maryland, Texas, Washington. So, people should consider the practice style that they like, and then the other thing that someone should consider is really becoming a cash practice in an upscale enclave where people can afford to pay for your care.
Kevin: That's kind of where I'm at. I'm in Boca Raton, Florida. So, I'm out of network with everything now except for Aetna, but it's an affluent area, and they can afford my cash rates which is on the higher end of things, and it makes it nice. I probably couldn't pull off what I do in certain other towns or cities.
Kevin M: Sure. What we see in talking with hundreds of doctors, there's haves and have-nots and some doctors have amazing cash practices, and if somebody wants to go that route, if they find and upscale enclave or suburb, they can do really well and avoid the insurance headaches altogether, but you do have to be in an area where people can afford your care if you're going to do that model. [0:16:24.4]
Kevin: Definitely, definitely. So, what's the difference between buying a practice from a broker versus just for sale by owner type of listings/
Kevin M: One of the biggest ones is if you have a for sale by owner situation, you're going to walk into, especially if the doctor is a little older, you're going to walk into a situation where the data is not going to be that clear. So, you're not going to have a big 40-page prospectus with three years of profit and loss really clearly spelled out and all the add-backs and personal things highlighted. [0:17:03.1]
So, it's actually kind of hard to purchase from an individual, and a lot of people come to us after trying to buy a practice from somebody, and they really wanted to buy that practice. So, we have what is called a facilitator package where if we have a willing buyer and a willing seller, we help them build a practice profile because it's very difficult to buy from an individual without the prospectus because where you'll run into a big roadblock is trying to actually get the financing for that practice. Everything needs to be really clearly spelled out in a way that the bank would accept it and qualify the young buyer for a loan for that practice.
Kevin: Perfect, and what are the steps to buying a practice? Basic skeleton of that, what would that look like?
Kevin M: I think first you're going to meet the doctor usually after hours on the first visit. You're going to check out the space. [0:18:05.2]
You're going to check out the equipment. You're going to see if your personalities and practice styles and philosophies and all that matches up. Once you have decided that a practice is right for you, you're going to make an initial offer, and that is in the form of a letter of intent which is a nonbinding offer. When we work with people, we provide a template for that, but the basics of it are the offer for the price. Then, you'll negotiate the accounts receivable separately. There will be the desired timeline for closing the sale, the desired transition, closing dates. Those will all be on the letter of intent. Once the letter of intent is fully negotiated and both parties agree, then that gets submitted to the bank, and that can start the process of getting funding for the practice, and then, in our case, we draft a practice sale agreement for both parties. [0:19:11.1]
Kevin: Okay, perfect, and then, how long does the acquisition process usually take in that scenario.
Kevin M: Once you have a letter of intent signed by both parties, it's typically 3 months to get an SBA loan, and that's probably 95% of the practices that we sell go through an SBA loan process through one of our banks. It can be done faster if everyone really jumps through the hoops and does their paperwork in a timely manner, but most doctors are busy, both buyers and sellers, so 3 months on average.
Kevin: Alright. Perfect. Perfect. Then, are practices worth more if they have the real estate attached to it? Is it worth the extra investment?
Kevin M: You know, they are much more attractive in the marketplace, and one of the things that I never got to do was own my own building, but I think that most people, if you look at the math, would agree, the best investment a chiropractor can make would be to own their own building instead of paying rent for 15 or 20 years and throwing that money down the drain. [0:20:21.5]
I have some buddies in Austin, Texas that built their only building back in the early 2000s, and their building are probably worth a million now.
Kevin: Yeah, that was my goal. I purchased my office space in 2013 at the low end of Boca at the time because it was still coming off the 2008 stuff and got it really low, and it's only been 6 years, and it's gone up quite a bit, and I'm hoping in the next 20 years, it just keeps going, right?
Kevin M: Yeah, that is the best long-term investment, and the other thing that I would point out, in smaller town and smaller markets, a lot of times, it's pretty affordable to get a building. [0:21:04.8]
You can get a building for $300,000 or $400,000, sometimes less, and the name of the game too besides getting people well is building wealth over time. Just as an example, Dr. Cheney who is actually a current business analyst, rockstar business analyst, he was in a small town in Kansas and paid off his house, paid off a couple of buildings, and retired early from chiropractics. So, that's something I would point people to as well.
Kevin: That's great, yeah.
Kevin M: Especially with where student loans are today, the numbers just don't add up to work as an associate or buy a really small practice or start from scratch in my opinion, in most cases doesn't make sense. [0:21:59.5]
Kevin: I think I've seen a little bit, and I don't want to generalize too much, but out of my audience, I am seeing a lot of chiropractors that are starting their practices inside of gyms or inside of CrossFits or small things like that where there is zero cost to do it, but then there is not a lot of margin either, and if they're not careful, they get stuck in that situation for the long term, and in a lot of scenarios, they are limited to the amount of revenue and profit they can make from it, and they don't graduate from that. So, I do want docs to be wary of that as well. It worked for me. That's actually what I did. It worked for me. A different type of setup, a different type of environment than most, but I think it is a struggle that people are running into. So, you've got to get into a nice office at some point. You've got to have...
Kevin M: I think that is something that I would point out to people too is you really want to begin with the end in mind and some kind of exit strategy, and so, the ones that are really hard to sell, shared spaces are really, really hard to sell. [0:23:07.3]
So, if there are two or three docs that decide to share a space and share an x-ray room and share staff, even if that doctor is netting or taking home $200,000 a year, when they go to try to sell that practice, they're not going to get the full value. They're not going to sell that practice for $300,000. So, we have trouble selling those, and we have quite a few in the gyms, as you said, and a lot of times, we're just finding very few takers to actually buy that practice in the gym. One thing to point out with that is you don't actually, as a seller in that scenario, you don't actually own the good will.
Kevin: Yeah.
Kevin M: You don't own the space, so you're basically selling off patient files and equipment at that point. Whereas if you were in your own practice with your own space with your own equipment, you're going to be able to sell that for a much higher multiple, and a lot of people get stuck with those when they try to exit. [0:24:09.9]
Kevin: I'm not shocked by that. What are some of the warning signs that should make you walk away from a practice if you're in the process of thinking you're going to buy it? What are some of the warning signs?
Kevin M: I think if you have someone try to sell your practice and they cannot accurately represent to you what the cash flow is, what the take home pay you would be enjoying as a buyer that would be red flags. A lot of people that try to do it on their own, which I have these calls every single week, or a lot of people will have a number in their head...I want $400,000 for my practice, but they really are not able to fully represent to you in a clear manner what the actual cash flow would be to support that asking price. I would also shy away from practices that have decreased year over year for the last three years straight. [0:25:08.4]
Kevin: Okay.
Kevin M: Those are hard to turn around.
Kevin: How about if...I've seen people run into a problem where the practice style was not congruent with how they practice, and they buy something that they end up having to a 180 on. Do you see that happening? Is that a red flag?
Kevin M: Yeah, well, I play matchmaker every day, and I try and talk people out of those scenarios. It almost never works out. For example, somebody is looking at a successful upper cervical clinic and they're not an upper cervical guy. It's just not in their blood, and they're like, "I think I would like to learn this technique and take over this practice." Those are risky situations in my opinion. You want to find....Some things I would recommend is find somebody that would be a really good mentor that already shares your personal philosophy of chiropractic and practices how you always envisioned yourself practicing. [0:26:10.1]
Kevin: I also would assume that it would be a benefit if you're buying the practice you already are an associate at maybe, right? Like if you're buying it from the doc that is there and you're there and you're treating the patients and they know you, that's probably a little bit of a safer bet?
Kevin M: Yeah, those are really good, and if you're ever an associate doc and you have a successful boss, I would be putting it in his ear and then say, "Hey, are you going to sell this place?" I would let the head doc know that you're very interested in buying at some point because that is a really good way to buy. You're not going to have the worry of attrition. You understand the systems in place. You're not going to worry about losing patients in that scenario. [0:26:59.9]
Kevin: Yeah. How about like, do you ever broker partnerships like getting someone into a partnership, buying into it, things of that nature?
Kevin M: Yeah, we do. We have the facilitator package I mentioned earlier. A lot of times, someone will practice for 30 years, and then they will sell to their associates as a partnership buyout, so we help people with that and other types of contracts as well. We also have people buying their way out of a partnership, and we give people advice on those as well.
Kevin: I wish I would have known you years ago when I bought out of a partnership. It worked out well for me, but it was a real pain in the ass.
Kevin M: We help people in a way we can help both parties understand what the value of the partnership is based on. One of the main considerations is what a bank would loan somebody on that practice. So, if it's worth $150,000 to sell that partnership, we'll be able to show them that once we have all the data and show if they were going to sell their partnership to another potential partner, what it was worth. [0:28:15.2]
Kevin: It makes sense. Alright, last question. What not to do when buying a practice? What are some things you are seeing that are just absolute pitfalls?
Kevin M: Man?
Kevin: It's a loaded question.
Kevin M: Rule #1 is, you know, a lot of the young buyers are millennials, and rule #1 is dress up, dress professionally, no matter if you think you're going to buy this practice or not, and you're looking at 10 other practices, like dress up, dress the part for each one. I've got some funny stories where someone showed up, and they were looking at a practice that netted $500,000 a year, and they really wanted it, and they showed up in holey jeans and an untucked T-shirt. I have a story where a guy was going to have a doc shadow him in the morning, it was Friday, they were going to take the afternoon off, he was going to show him the whole town, and this guy shows up in holey jeans, and shadows for a little bit, and then he gets shown the door. [0:29:23.0]
Kevin: Ah.
Kevin M: He really wanted that practice and didn't get it. So that very same buyer, the next practice he looked at, I was like, "Look, wear a tie, act professional, show up, be professional, and impress the seller." The buyers have to realize that it is a two-way vetting process. They are kind of being interviewed with being a good prospect to take over somebody's patient base and take care of their patients and staff that they have grown very close to over the last two or three decades. So, be professional. [0:30:04.4]
Rule #2 is don't ever lowball a practice. A lot of people are under the misconception that the best way to get a good deal is to throw in a lowball offer first with hopes of landing somewhere in the middle, and so people lose practices that they wanted all the time because the initial lowball offer killed the goodwill they had with the seller, and so then, they never get the practice that they actually wanted. So, be professional in your negotiations. Anything that we would put out there, we know that it's worth very, very close to the asking price. There is some give and take in negotiations, but you want to have a really good reason also for offering lower than the asking price and highlight what those specific concerns are. Don't just throw out a lowball offer. I see a lot of people losing deals by doing that right out of the gate. [0:31:10.7]
Kevin: So, you do help docs with the negotiation process and coming up with maybe a good counteroffer and things of that nature?
Kevin M: Yeah, we really guide both parties, and if there is a seller and there are legitimate concerns about their practice, for example, if the x-ray and the EHR and some of the equipment needs to be updated, those are legitimate concerns why someone might want a discount and why you're not going to get top dollar for that particular practice. So, what we do all day long is guide people to a win/win transaction where both buyer and seller are happy at the end.
Kevin: Yeah, one thing I wanted to ask, and this is a marketing and business podcast, so I like to ask the marketing things. Like for my practice, we put together a very well-developed marketing strategy year end, and I've got records of it. I've got an email list. I know exactly how many people, followers on Facebook, all the different things, a really distinct marketing strategy. Does that help the seller as far as the sellability of a practice when you can say, "Hey, look, this is what we've been doing for the last 5 years, and this is what it looks like, and this is the email list, and this is all that. Will that help? [0:32:25.9]
Kevin M: It really does. I think when it comes to selling your practice, it's all about the goodwill that you've created in the community, and it's about the unique selling propositions of selling the actual opportunity. So, if someone has marketing that's working and has been working for years in the community, that's a huge selling point that makes it a much less personality driven practice. So, back to advice for buyers, is I would look for a practice to buy that has those systems in place, you know, marketing that's working and new patients coming in the door outside of the doctor giving talks and health screenings and things like that. You want to buy systems and cash flow, in my opinion. [0:33:17.5]
Kevin: Yeah, it's like I know, we're anywhere from 8 to 15 new patients from Google alone, and that's something that is just automatic, and it's just because we created a lot of content and we've got a lot of reviews, all that type of stuff working behind the scenes to generate those new patients which really wouldn't change if I wasn't here.
Kevin M: Yeah, that's extremely valuable. I would say the more streams of new patients you have coming into the office would not only make you have a healthier practice, but as an exit strategy when you're speaking to buyers, that will make them less apprehensive about buying your practice. So, professional relationships, the other marketing that you mention, other things that are working outside of referrals because everybody's got a referral driven practice. The sellers that have a lot of sources of new patients have a much easier time when it comes to time to sell their practice. [0:34:12.8]
Kevin: Perfect. That makes sense. Any last pieces of advice for our audience regarding this really important topic that I think a lot of times flies under the radar?
Kevin M: You know, I would say for both buyers and sellers, start the process early. We're talking to lots of docs while they're still in school about what they should do when they graduate, and the name of the game as a buyer is find out what kind of down payment money you are going to have access to. A lot of buyers really need to know that you can borrow the down payment from family, and you need to find out, if you can get 10%, then you can start to look at practices in your price range. So, if you might be able to pull together $30,000, then you can a $300,000 practice. [0:35:01.6]
If you can pull together $50,000, you can look in that $500,000 range, and then for sellers, don't wait until you blow your shoulder or have a heart issue or something like that before you start thinking about selling your practice. A lot of people say, "Kevin, I wish I would've called you two years ago." They call and something is going on with their health or other issues, and they need to sell in a hurry, and they're going to really lose out on the value that they could have had if they just planned a little earlier.
Kevin: Perfect. That makes sense. Well, you know, I really appreciate your time and great information today. How can our audience find you if they have any questions or want to touch base with you on this topic?
Kevin M: You can reach me at Kevin@progressivepracticesales.com.
Kevin: Perfect, and I'll put that in the show notes, and I'll put the website in the show notes, and everything there. So, I appreciate your time today.
Kevin M: Yeah, it's been fun. Thank you so much.
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