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Howard Farran:
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It is a huge honor today to be podcast interviewing Kevin Mosher, who is the CEO or Clearchoice Dental Implant Centers in the greater Denver area. He used to be the CEO of Define Inc. for three years in San Francisco and what's amazing is he used to be the president of North America Nobel Biocare for five years and you're from the United States Naval Academy. Congratulations on that. What a feat.
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Kevin Mosher:
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Thank you. Thank you.
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Howard Farran:
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How did you get into the Naval Academy? That is a feat of all feat. That must be the most competitive thing you ever did in your life.
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Kevin Mosher:
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It was a long time ago now. It's a very-
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Howard Farran:
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Did they have boats back then?
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Kevin Mosher:
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They had boats and they were made of metal, not wood. It wasn't that long ago. You had to get a nomination from a Congressman or a Senator in order to apply. Then you applied and, based on academics and interviews and so forth, if you were lucky, you would get an appointment. I was lucky enough at the time. I had hoped to fly, but I played football at Navy, as well, and I hurt my knee, so I was unable to do that.
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Howard Farran:
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How did you get from the Navy to the president of Nobel Biocare?
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Kevin Mosher:
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After I got out of the Navy in 1990, I went into medical devices. I started out in sales with Baxter Healthcare Corporation. I went to work for Johnson & Johnson after that. I was there for a number of years and moved from sales up into marketing and management and eventually worked my way up through the ranks, so to speak. I was president of a medical device company in Irvine, California. It was a startup that went public and Nobel recruited me from there to be president of their North American division. If you look at my career, for the last 26 years, it's been medical devices, dental devices, that type of thing.
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Howard Farran:
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What years were you at Nobel Biocare?
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Kevin Mosher:
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2004 to almost the end of 2009, so I was ...
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Howard Farran:
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What was the time frame of when the big monster conglomerate Danaher swallowed that fish?
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Kevin Mosher:
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Gosh, that was in 2014, I suppose.
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Howard Farran:
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It was long after you.
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Kevin Mosher:
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Yes, yes.
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Howard Farran:
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Because you're the CEO of Clearchoice and didn't they only use Nobel Biocare implants and then recently switched?
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Kevin Mosher:
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That's correct. When I was president of Nobel, that was when Clearchoice started up, so I had a relationship with Clearchoice back then as a supplier. They were exclusively Nobel up until we switched. The official switch was the end of February 2015.
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Howard Farran:
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What did you switch to?
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Kevin Mosher:
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Straumann and Neodent. We use a combination of the Straumann and Neodent implant systems. Of course, Neodent is now a part of Straumann, so it's wholly owned.
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Howard Farran:
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Was Neodent from Brazil?
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Kevin Mosher:
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Yes.
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Howard Farran:
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Now, they may be picking up another property, Megagen, in June. Isn't there a deal on the table where they could accept it on June 1st?
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Kevin Mosher:
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I'm not sure exactly the timing of that deal. I know Straumann has an ownership stake with options in Megagen, is my understanding. It may be that they're moving forward with that.
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Howard Farran:
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Before we get into Clearchoice, when Danaher bought Nobel Biocare, which was the high end Mercedes Benz, Cadillac, top of the line, I don't think anything's more- that has roots to the inventor of implants, [inaudible 00:03:48]. Then they bought the low cost Implants Direct right here in California. Was that like General Motors saying, "I want to have a Cadillac, a Buick, a Pontiac, a Chevy"? Was that price segmentation or did they see synergies of management and production or will they be left as two totally separate companies? What was your thoughts on that merger and acquisition?
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Kevin Mosher:
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It was the opposite way. They acquired Implant Direct first, so they owned Implant Direct for a number of years. Then they bought the Cadillac, as you say. Hard to speculate exactly what they're looking at, but if you do view the market, though, it's clear that what they call the value segment, the lower cost implants, have really taken hold and I think clinicians are finding the results are really good. If you want to be in implant dentistry at the high end level, it seems you have to have some position in the lower end or else you'll end up with a, although you might have a great share of the premium market, it'll be a shrinking share of the total market. I think that's probably what many of these premium implant companies are wrestling with is how do we ensure that our R&D funds don't shrink and dry up because more and more the market is going away to the value segment.
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Howard Farran:
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You're talking to dentists right now in 141 different countries, from here to Kathmandu, so why don't you explain the Clearchoice Dental Implant Centers that you're the CEO of? Why don't you tell us that story?
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Kevin Mosher:
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Sure. The company was founded by a dentist, Don Maloney, and he had previously run denture implant clinics. The issue and the challenge he faced with denture clinics, I don't know if I said denture implant clinics, I meant denture clinics, is that patients are frequently dissatisfied with the solution. Their bone was constantly remottling, so they had to be realigned, the dentures, that is. He felt a fixed solution would be a great way of providing a more optimal solution to the patients. He founded Clearchoice on that principle.
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The other things though, in terms of delivery, that he thought were imperative was the ability to provide all services in one location. Implants from full arch treatment require a surgical prosthetic and a laboratory component. Patients nowadays, they want to go home with teeth. If you try to implement a solution for a full arch case with the traditional referral system, it's more challenging because the general dentist has to refer to a specialist who places the implants, but then what happens? Is there a laboratory technician at the specialist's office? Typically not, but that would be required if you're going to convert the denture at time of surgery so the patient goes home with teeth. Then the patient has to go back to the restorative office. There's just a logistics issue, I think, for patients.
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The Clearchoice model is built on optimizing a clinic to do full arch rehabilitation with the idea that the convenience is for the patient and not for the clinician. In other words, the patient does not have to conform to the referral model system. The patient can go to a single center and get their treatment.
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Howard Farran:
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We have to put patients first. I was listening to a speech by the founder of Google and he says whenever they get to a fork in the road and there's confusion, they just simply ask, "Well, what would be best for the customer?" It's like when you get a remote control. I've never met anyone who can understand a remote control is because when the remote control goes to production, every department is trying to get their buttons in and their sets in. If Steve Jobs built our TV remote control, he'd start with the end user first and say, "What is the easiest for Kevin? How is Kevin going to have the easiest, simplest remote control?" That's why a lot of dentists thought implantology should be a specialty, but the oral surgeons have a stake in it, the periodontists have a stake in it.
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Have you been following the Texas lawsuit with the courts about the dentist was saying that he was a implant specialist and the American Dental Association said, "That's not a specialty." The Texas courts ruled, "Well, the American Dental Association is a membership club. They're not a state regulatory agency and, yes, it sounds like indeed you do just implants and, yeah, if that's all you do, that's all you do." There was nothing untruthful about the statement. Have you been following that case?
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Kevin Mosher:
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A little bit, but not super closely. The irony in medicine in general is that if you are a specialists, in other words, you adopt a specialty, then you're held to accountable to do what is in the realm of that specialty. If you're a generalist, you pretty much can do anything if you've gone to dental school. That's a precedent that's well set in implant dentistry. More are placed by general dentists than by specialists. That data is available.
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Howard Farran:
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That was just for the first time 2015, was that the year that it tipped over to more implants placed by American general dentists than American specialists, like oral surgeons and periodontists? Was the the first year it happened, 2015?
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Kevin Mosher:
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If that's the information that you have, I feel that it's later than what I felt it was. Millennium research group were the company that we used to rely on at Nobel. I seem to recall that it happened even sooner than that.
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Howard Farran:
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What year did you see it happen?
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Kevin Mosher:
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I believe it happened in the mid-2000s, 2005, 2006 time frame. The reason being is that it's the sheer number of general dentists. The average general dentist will not do nearly as many implants as the average specialist who focuses on implants, but there's so many more general dentists, so demographically, if a generally dentist is doing 10 or 12 a year and you've got 35% of the general dentists doing it, it's far more number than the specialists doing 100 implants a year.
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Howard Farran:
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How many Clearchoice Dental Implant Centers are there in the United States?
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Kevin Mosher:
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Right now, there's 20 full service centers and we have two remote consult sights, so two centers that have a practitioner there. We do consults, but they don't do the full service.
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Howard Farran:
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20 centers in how many states.
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Kevin Mosher:
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29. In 18 states.
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Howard Farran:
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20 centers in 18 states.
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Kevin Mosher:
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29.
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Howard Farran:
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Oh, 29 states-
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Kevin Mosher:
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Yeah, in 18 states.
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Howard Farran:
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In 18 states.
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Kevin Mosher:
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Correct.
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Howard Farran:
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Which states have two?
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Kevin Mosher:
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California has five. Actually they have ... yeah, they have five. We have two in Chicago. We've got five in Texas. I think those are our states with multiple locations right now.
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Howard Farran:
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Two in Chicago or two in Illinois?
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Kevin Mosher:
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Illinois. I'm sorry.
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Howard Farran:
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Are they in the Chicago Metro?
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Kevin Mosher:
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We have one in Chicago Metro, one in Schaumburg, Illinois.
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Howard Farran:
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Schaumburg, what's my little favorite company in Schaumburg, by [inaudible 00:10:59], [inaudible 00:11:02].
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Kevin Mosher:
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Yeah, that's right.
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Howard Farran:
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Is he involved in it in any way?
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Kevin Mosher:
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No.
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Howard Farran:
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I think the ... you have a location here in Phoenix. I want to tell you, ever since- You guys remember when that opened up in Phoenix?
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Kevin Mosher:
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Gosh, it was before I was here. It was probably in the 2007 time frame, 2006, 2007.
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Howard Farran:
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You know what I like most about the Clearchoice centers from a selfish point of view?
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Kevin Mosher:
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What's that?
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Howard Farran:
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You guys do so much marketing and then my patients that have been coming to me for three decade come and tell me about all of your commercials and infomercials and asking questions about it and I always see a Clearcenter is raising the tide for all the big boats, the small boats, and the little canoes.
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Kevin Mosher:
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You're exactly right. You're exactly right.
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Howard Farran:
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How much money do you spend on advertising? Is it mostly television?
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Kevin Mosher:
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That's private, it's confidential what we spend, but we do spend millions on advertising.
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Howard Farran:
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This is Dentistry Uncensored, so don't worry about anything, any lawsuits or anything.
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Kevin Mosher:
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It's a combination of-
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Howard Farran:
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It's millions of dollars.
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Kevin Mosher:
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Millions, yeah, tens of millions. It's a combination of television advertising, print advertising, and now digital media, so we combine the three. It's interesting what you- the comment that you made about lifting all boats because when I was at Noble Biocare, there was a lot of concern about Clearchoice in the early going, would Clearchoice steal patients and what would that mean for my dental practice and so forth, so a lot of our specialty customers at Nobel were very sensitive to what Clearchoice was doing. The interesting thing is that, when we tracked the data, we found that the growth of our implant specialists in markets where Clearchoice existed grew at a faster rate than the rest of our customers in general. The data showed that the rising tide did lift all boats.
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Howard Farran:
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Oh my god, I had been seeing that first hand in Phoenix forever. You guys generate pretty much all of my implant leads in my practice. I just got to hand it to you. It's amazing. When you said television, print, digital media, what is digital media?
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Kevin Mosher:
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We'll do a number of different things digitally, which is social media. We'll do paid search, which is when people are searching, we'll come up at the list, so to speak. Then all of the things that go along with that, when they click on the results of a paid search, we'll drop cookies and then continue to advertise to folks. A lot of our- kind of the track that people take into Clearchoice is they'll see a television commercial or several television commercials and then they'll go online and that's when they really start to educate themselves. They'll often book their appointment from their website or from a mobile device, so our website is also optimized for mobile, as well.
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Howard Farran:
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Do you have a 80/20 rule of your standard case? Is your average client/patient a fully [inaudible 00:14:19] getting four on the floor upper and lower? Do you do single tooth or are people just replacing partial bridges? What's going on? What is your ...
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Kevin Mosher:
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It's a great question because I think there's a lot of misinformation in the marketplace and I think the misinformation is that all patients are a all on four patient, no matter what. About 16%, roughly, of our patients, just the way data has run in the last couple of years, are singles and multiple implants, so it's not 100% all on four. We do focus on the full arch, so a lot of our patients either are in a denture or they have failing dentition, terminal dentition that will be extracted prior to a full arch rehabilitation. The average, actually interesting data point from last year, the average implants per arch was 4.2. that will tell you we mostly do all on four, but we don't always do all on four in our center.
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Howard Farran:
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Explain, there's people- I'm sure there's homies listening right now that don't know what an all on four is.
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Kevin Mosher:
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It used to be, in the older days if you will, that for a full arch case, patients would often have the bridge would be supported by six to eight implants, sometimes more, but traditionally around six to eight implants. What was discovered was that you actually, bio-mechanically, only need four implants to support the prosthesis and the extra implants don't necessarily provide additional support. Also, we tilt- often our clinicians will tilt the implant so you can place the implants where there's available bone and then through a multi-unit [inaudible 00:15:55] and a multi-angle [inaudible 00:15:58], you can actually correct to vertical so that you can attach the prosthesis. It enables many, many more patients to be able to get full arch rehabilitation without bone grafting.
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Howard Farran:
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It's simple geometry. If you have an implant going straight up versus one going at a 45 degree angle, you can get so much more length, so you get so much longer implants with more osseo integration.
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Kevin Mosher:
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And more posterior/anterior spread, so you get less cantilever on your prosthesis. Then with cross-arch stabilization- when I was with Nobel, it's interesting, a dentist up in Canada, Ivan [inaudible 00:16:39], he published in the '90s on tilted implants and the success rates that he had, but is was somewhat controversial. Then [inaudible 00:16:46] in Portugal, he really commercialized this all on four concept and, again, he was tilting the implants.
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In 2005, when Clearchoice started up, it was somewhat controversial and Nobel was a big proponent of the all on four with tilted implants. We've now, at Clearchoice, we've treated over 40,000 patients with an all on four concept over a 10 year period. We have tremendous experience doing this and tremendous results, quite honestly.
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Howard Farran:
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It's roughly 25,000 bucks an arch, basically.
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Kevin Mosher:
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Roughly, yes.
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Howard Farran:
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Roughly. What if a patient said, "What's your success rate?" How do you answer that?
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Kevin Mosher:
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It would be clinic by clinic. For example, in Phoenix, I know that their success rate is north of 95%. Dan Galindo, the prosthodontist there, has kept track of all of his patients. That's typically what we see throughout the network. It's extremely high.
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Howard Farran:
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What's his name?
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Kevin Mosher:
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Daniel Galindo. It's G-A-L-I-N=D-O. He's our prosthodontist there. He's been there since the very beginning.
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Howard Farran:
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You think the success rate is so high in Phoenix because it's so damn hot that periodontal disease bugs just die in the 126 degree heat with no humidity?
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Kevin Mosher:
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I don't want to take away from our centers, but I do suspect there might be something at play there.
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Howard Farran:
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Oh my god, it gets hot in the summer here. Living in Denver, I'm sure you'll only come down here in the winter.
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Kevin Mosher:
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That's right.
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Howard Farran:
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You make all your trips-
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Kevin Mosher:
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Escape the Denver winters.
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Howard Farran:
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You said Palo Malo, Paulo Malo, that's M-A-L-O-
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Kevin Mosher:
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Yes, that's P-A-U-L-O, Paulo Malo, M-A-L-O.
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Howard Farran:
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He's a legend out of Portugal.
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Kevin Mosher:
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Yes.
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Howard Farran:
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Just a legend. That guy's one of the biggest names. What was the name you said before that?
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Kevin Mosher:
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Yvan Fortin. That's spelled Y-V-A-N and Fortin is F-O-R-T-I-N.
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Howard Farran:
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Was he Scandinavian? Was he up there with Nobel Biocare?
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Kevin Mosher:
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He was using Nobel Biocare, yes. He had practices in Montreal and Quebec and Quebec City, I believe. I've been to his Montreal practice. He published as early as 1992 on his results with tilting of implants. It's a misconception. A lot of people think that Paulo Malo invented the tilting of implants as a means of supporting a prosthesis. It was done before him, but he had a big role in commercializing a very proven technique to drive high success rates with an all on four.
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Howard Farran:
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You see him lecturing everywhere. It seems like so many times, I've been in a foreign country and he's been on the program or people are- when they talk about implants, it's just the world according to him. It's an amazing legend. Are you still expanding centers? This is 2016, are you going to open up another center?
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Kevin Mosher:
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Yes.
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Howard Farran:
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What's your plan for this year, five years, ten years?
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Kevin Mosher:
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We're going to be opening up six centers this year. The idea for us right now is to roughly double the size of our network over the next three years.
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Howard Farran:
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You're going to double in three years.
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Kevin Mosher:
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Yes.
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Howard Farran:
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What percent growth rate is that?
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Kevin Mosher:
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It would be 100%, in terms of number of centers.
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Howard Farran:
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I mean yearly.
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Kevin Mosher:
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We're looking at this year we're going with six centers and then the balance to double would be approximately 10 to 12 centers over the next 12 years following that.
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Howard Farran:
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Wow. That means you're a busy man.
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Kevin Mosher:
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We went through a period where we went went from our founding in 2005 to fairly rapid growth. Then the last couple of years, last probably three years, we've really slowed down and optimized the network. We added a new center late last year, Tampa, Florida. That was our get the rust off of opening new centers and now we're starting to march forward.
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Howard Farran:
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Do you try to go where there's more grandmas and grandpas than young baby boomers?
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Kevin Mosher:
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Yeah, we do a lot of research to determine what is the optimal location for a Clearchoice. After 10 years and millions of phone calls, we have lots of data. We've actually worked with a credit agency, Experian, to create our own filters for demographics to determine likelihood to move forward with our procedure. We also have a tremendous luxury, which is we've advertised- Our advertising is part local advertising, part national advertising. The benefit we have from 10 years of national advertising is we know where every one of those calls is coming from, so we can heat map them. We generally know demographically does the area that we're contemplating support a center and then we can determine level of interest going back in time. On top of that, we'll apply some of the same software analytics programs that a Starbucks would use to determine drive times and that sort of thing because we have a good understanding, based on distance from center and drive time, the likelihood of people moving forward. We bring all those data points into play and we generally find that's how we'll find good locations.
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Howard Farran:
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Who is your customer?
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Kevin Mosher:
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Our general customer is 40 to 69 years of age, so it's-
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Howard Farran:
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Really? It's 40?
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Kevin Mosher:
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Yeah. We've had lower, but it's not a big part of our demographic, but generally 40 to 69 years of age.
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Howard Farran:
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What would the median mean be?
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Kevin Mosher:
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I don't have the data right off the top, but I would say the mean is probably in the high 50s.
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Howard Farran:
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Is it more likely to be grandma or grandpa? Is it a vanity issue?
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Kevin Mosher:
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No, it's not a vanity issue. I was going to say it probably leans a little more female, but it's-
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Howard Farran:
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It's half and half.
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Kevin Mosher:
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It's fairly half and half, yeah.
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Howard Farran:
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It's form and function and aesthetics.
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Kevin Mosher:
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Yeah. These people are generally either have their teeth are floating in their head, they've had severe periodontal disease. Periodontal disease is the leading reason why people come see us. What's interesting, I think, is the patient journey. Typically, these patients went to the dentist throughout their lives and they became frustrated with dental care. To no fault of the general dentist, they had an advancing disease state that was going to eventually lead to terminal dentition, so they struggled with constantly going to the dentist, paying lots of money to fix one tooth at a time type thing. Eventually, they checked themselves out of the system. Usually when a patient shows up at Clearchoice, they haven't been to a dentist for five to seven years. It's not always, but that's the typical patient.
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A lot of times when doctors in the market think that we may be taking their patients, they often don't realize that these patients haven't been to a dentist in years. Finally they get to the point where they have to do something and they'll see one of our advertisements. Typically, they're thinking dentures, "I have to do something, I'm probably going to have to go to dentures." They fear that, particularly the baby boomers. Then they see an ad, teeth the same day and things of that sort, and they respond. That's typically how a patient comes into our system.
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Howard Farran:
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When we had the financial meltdown of 2009 when Lehman's collapsed, et cetera, was there a sharp contraction in the amount of people wanting these high end services? Did it respond like a discretionary luxury item or did you guys keep chugging along?
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Kevin Mosher:
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If you look at the data, we kept chugging along, If you look at our revenue growth. If you think about it-
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Howard Farran:
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You grew through those year?
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Kevin Mosher:
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Yes.
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Howard Farran:
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Unbelievable evidence that this is really important.
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Kevin Mosher:
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If you think about it, when I used to talk to Nobel about this, in the range of, say, 16 to 17,000 full arch cases are done in the US throughout the year, as a data point 16 to 17,000. When you consider that there are over 35 million Americans in dentures, you don't have to take much market to have a business, you know what I'm saying.
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Howard Farran:
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How many dentureless Americans are there?
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Kevin Mosher:
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Over 35 million.
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Howard Farran:
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35 million. It's so funny because now that I've been out of dental school three decades, so many of the predictions went crazy wrong, like we were told that dentures were coming to an end. People were asking why we need to make dentures, but here it is three decades longer and the units of dentures per year has been growing every year since I got out of school.
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Kevin Mosher:
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That's right. There's a research paper out of Harvard, Chester Douglas, he's a DMD, PhD, and the paper was published in 2002. The whole purpose of the study was to determine should they continue to teach dentures in prosthodontics school. That paper is the paper that I refer to when I tell you those numbers over 35 million. He showed that the rate of edentialism was declining at a rate of 1% a decade, but the absolute numbers of the baby boomers were pushing the overall numbers up. His paper covered through 2020, when there was about 36 and a half million Americans in dentures, so, yeah, precisely what you said. They did a study that said, "Hey, you need to do this."
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Howard Farran:
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I'm going to say something that's going to be very biased because I'm in Phoenix, Arizona, 100 miles from the Mexican border, but I seem to do a lot of dentures on people who just immigrated into the United States. Just because they came in from the Mexican border, they could be from anywhere, South America, Europe. I think the last one I did, I forget, I think it was ... they were Romanians or whatever, but it seems like a lot of immigrants are still feeling the dentures. Do you see that?
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Kevin Mosher:
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We do. We have immigrants that come to our centers, but if you look at the statistics, and these statistics are from Centers for Disease Control, the rate of edentualism per state is quite high across America. It skews lower at the coasts, but when I say lower, 16%, in that range, is roughly the number for New York, compared to West Virginia's in the 40s, but generally you're seeing 16% to high 20s is not uncommon state by state.
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Howard Farran:
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West Virginia is 40%?
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Kevin Mosher:
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I think it's 42 or 44%, yeah.
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Howard Farran:
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42% of people over 65 or just 42% of the state?
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Kevin Mosher:
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Of the state. The rate of-
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Howard Farran:
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42% of West Virginians have no teeth?
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Kevin Mosher:
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The Centers for Disease Control, and I'd have to check that to be certain whether they had a demographic range. It's maybe adults, but it's been a while since I looked at the numbers. You can Google Centers for Disease Control edentialism and you can actually find the state by state statistics. It may be adults. I can't recall exactly.
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Howard Farran:
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The last I can remember from the CDC from a couple of months ago, basically in a nutshell it's at 64, 10% of Americans were edentualists, at 74, 20% was. Then in both age ranges, times two for missing half their teeth. At 64-
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Kevin Mosher:
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Yeah, it probably is an adult thing, now that you mention it. It's too high for the general population.
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Howard Farran:
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I was born and raised in Kansas. I shouldn't be saying this, but when I was little, all my grandmas and grandpas, they all had full dentures. A lot of the grandpas didn't even wear the teeth because they were so ill fitting. I had one grandpa that threw his off on the tractor and plowed them over and never wore teeth again just because they were so ill fitting. George Washington, his entire career was always set back by pain and abscesses and things like that. I always wondered why he didn't pull them all of and live like my uncles. It was amazing.
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The thing I love about the Clearchoice Dental Implant Centers also is your centers are known for opening their doors to the dental community. Any dentist that refers a patient down there, I've been told by my friends, "Yeah, I referred a patient to Clearchoice Center and I asked the doctor if I could come assist the procedure and he said, 'Heck, yeah'." Total transparency. Talk about that. Is that a center by center or is that a national policy?
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Kevin Mosher:
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We don't set national policies for our centers relative to how they do their clinical work. They make those decisions, but I would say generally, center by center, they'll do that. The interesting thing is early on, I think that what caused a lot of consternation about Clearchoice was the unknown, "What are they doing in those centers" and so forth, so we have opened up our centers to the professional communities. In fact, some of our centers are doing incredibly strong referral programs where the general dentists in the communities, some of these patients that I say had become frustrated and had checked themselves out of the dental system, our prosthodontists work with the general dentists to help identify those patients. The general dentist refers those patients to the Clearchoice center.
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There's some real benefits to it because what we'll do is we'll do the surgery. Our lab techs will convert the dentures at the time of surgery with the help of the prosthodontist to check for the occlusion and so forth. Then the patient will be referred back to- The patient goes home with teeth. They have their [inaudible 00:30:39] teeth the same day as surgery. The patient will go back to the GP who referred for their final restoration. Depending on what they do, sometimes we'll help them make the final restoration in the laboratory, depending what they do, they'll make between 4 and $6,000 for the restorative fee for that patient.
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It's really worked out well because if you think about the challenges in a referral system, the general dentist, if they refer to a surgeon who doesn't have a lab tech available, what do they have- They have to go over there themselves and they have to help convert the denture, they have to check the occlusion, so there's an opportunity cost because they're out of their practice. When they refer to Clearchoice, they know the patient's going to be treated extremely well in a very high end practice that's optimized for doing that procedure and the general dentist can stay in his or her private practice for the day and continue to do crown and bridge work and cover their overhead. Then the patient comes back and they do the final restorative fee.
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It's a good fee, as you know. Full arch fee for a restorative dentist is a very good fee, particularly when they can offload a lot of the burden to Clearchoice. That's worked very, very well in many of our markets.
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Howard Farran:
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Who owns Clearchoice? Is it publicly traded? Is it an individual? How does that work?
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Kevin Mosher:
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It's majority owned by a private equity firm called Catterton Partners, C-A-T-T-E-R-T-O-N, Catterton Partners. Then the balance is owned by- Our founders still have a stake in the company and there are quite a few doctors who have an ownership in Clearchoice, but the majority is owned by Catterton Partners, a private equity firm.
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Howard Farran:
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What is their exit strategy? I want to ask you, I'm known for asking a question that's got 28 questions within a question. What is your view in general about DSOs? I'm wondering why a private equity firm has this because you take something like the biggest one, Heartland Dental [inaudible 00:32:43] in [inaudible 00:32:43] Illinois. You would think that if that was a really good, profitable, growing business, all of those brokers on Wall Street would have loved to do an IPO, it would be trading on NASDAQ. When I got out of school, Orthodontic Centers of America was trading on the New York stock exchange and there was a dozen on NASDAQ. They all imploded and disappeared and then Rick eventually sold some portion of it to a Canadian teachers' pension plan. Does that say something about DSOs, if they can't do an IPO that there's something- Why wouldn't that be an IPO? What's different between Heartland and an iPhone?
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Kevin Mosher:
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What's different perhaps may be understanding, the general public market understanding of what a DSO is, but my feeling is that the fact that private equity is very, very involved in DSOs, the fact that the Toronto Teachers' Union buys a DSO, it tells you something. This is what attracts them: a general dental practice, let's take that and Clearchoice, the same kind of thinking applies. People have to get dental care, so it's very predictable. For a private equity firm, they know if this DSO has 100 locations, we can take it to 300 locations and generally get three times the value in the transaction. It's consistent returns that I think private equity- it's very predictable. It's what I think the like, it's what I think the Toronto Teachers' Union probably liked.
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The benefit of a DSO is you're taking an industry that, let's face it, is quite inefficiently set up. It's a cottage industry. You have thousands and thousands of practices and they replicate all the overhead and all of the administrative burden that goes with a practice. When you go to a DSO, you centralize that administrative overhead and burden and you get tremendous efficiencies. The finance department at Clearchoice to support the business we do is tiny. We can enable the clinicians to do what they do best, which is good clinical care. Our costs, because we pool the services, we pool our purchasing. What location buys 35,000 plus implants a year? That's buying power. As a result, we can deliver care more efficiently, at a lower cost, and thereby increase access. I think that's the number one thing about a DSO, increasing access to dental care.
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I think it is very attractive. I think over time as the industry becomes more knowledge- when the general public becomes more knowledgeable of the industry, I think you can talk more of IPOs, but right now, the private equity guys love it and it's because-
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Howard Farran:
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What do you think their holding time will- How long has Catterton Partners had portion of Clearchoice and what's their holding time?
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Kevin Mosher:
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They've been in about four and a half years. Generally, and I say generally because it can vary quite a bit, but generally, private equity holds a company for about five years. They'll have a fund that they raise a fund and they invest it in various companies and the average holding time for companies invested in will be about five years. That means, in some cases, they're selling after two or three, and other cases they're holding seven or eight. Catterton right now is in their fifth year. My sense is that at some point, probably in the next, I don't know, let's speculate, year to two years, they'll probably look at an exit.
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Howard Farran:
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Do you think it'll be the Canadian teachers again?
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Kevin Mosher:
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I think that it's interesting. It could be likely another private equity firm we have a very small footprint for a company that advertises nationally. We have right now 29 locations. You can easily imagine us having 70 or 80 or 90, so I think that another private equity firm would potentially look at us for the shareholder value that could be created with growth, coming in and providing the capital to grow more aggressively.
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I think that if you look at, there are a number of DSOs that we talk to. When you consider the referral model that I talked to you about, these DSOs, when they look at the average return per chair hour, it's substantially lower than a Clearchoice. The average Clearchoice is doing six to six and a half million dollars a year in collections with one and a half doctors. You don't typically see that in a general dental practice. They're interested in the possibility of increasing the value gained per patient visit. I think that they see some synergies with the general dental practices referring to the specialty practices and then back. There's a number of DSOs that I think see that as a real option with a Clearchoice type model.
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Howard Farran:
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Of purchasing, you mean? Of purchasing?
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Kevin Mosher:
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Yes.
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Howard Farran:
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You're talking Rick [inaudible 00:38:06] or Steve [inaudible 00:38:06]?
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Kevin Mosher:
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Well, I'm not talking about either one of them. I'm talking about large DSOs that have needs.
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Howard Farran:
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Are they arm wrestling over it now?
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Kevin Mosher:
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No comment there. We have talked to DSOs and I think they see- Some of these DSOs have tried to get into implant procedures and they've been creative in doing it. The problem is one of time, so therefore cost, and the other of liability. If they try to do an all on four procedure, I've talked to some of them, they take sometimes half the day to the full day, whereas we can, in half a day, do two or three. They're just not optimally set up for it, so it's reinventing the wheel every time they try to do the procedure. Then what kind of exposure do they have liability wise when they have patients under anesthesia and so forth in a general dental practice. If they could instead refer those patients out, continue to work in their practice doing crown and bridge work, the things that are their bread and butter, and then the patient comes back and they're spending 45 minutes to an hour of chair time and making 4 to $6,000, it's attractive. I think that's what they see. That is a possibility, I would say, as well.
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Howard Farran:
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Who are these doctors? Are they mostly oral surgeons? Are mostly periodontists? Are any of them general dentists?
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Kevin Mosher:
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In Clearchoice?
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Howard Farran:
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Yes.
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Kevin Mosher:
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Yeah, in ClearChoice, all of our surgeons are oral surgeons, so every center ... The oral surgeons in Clearchoice typically have a private practice, as well, so they'll often come four half days a week. The restorative dentists in our clinics are prosthodontists. They're there four full days a week. We're open four days a week.
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Howard Farran:
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The prosthodontists are full time and the oral surgeons do four half days a week?
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Kevin Mosher:
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Correct.
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Howard Farran:
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Is that just a cultural thing because [inaudible 00:40:02] was an oral surgeon? Do periodontists try to get in there or is it a belief that the oral surgeon is just more trained in the whole big picture?
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Kevin Mosher:
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I think so. I know there are periodontists that can do great work with all on fours and implants. The legacy of the oral surgeon goes back to our original founder and his belief was-
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Howard Farran:
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Who was that?
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Kevin Mosher:
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That was Don Maloney.
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Howard Farran:
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Oh, Don Maloney. Then what was Olly's role?
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Kevin Mosher:
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Olly was the first oral surgeon, so he- Don Maloney, because oral surgeons-
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Howard Farran:
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He was a general dentist?
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Kevin Mosher:
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Don Maloney was a general dentist. He hasn't practiced probably since the late '70s, early '80s. He's owned a lot of dental practices, denture clinics, a dental insurance company, and so forth. The feeling was that oral surgeons get anesthesia training as part of their general curriculum as they're going through school. He felt that that was the best way to ensure optimal patient outcomes, safety, and so forth. Olly Jensen was the- The early founders of our company recruited Olly Jensen of the first oral surgeon in our Denver clinic and Mark Adams as the first prosthodontist. They actually recruited him from Michigan.
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Howard Farran:
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Oral surgeons come in a half day four days a week and your prosthodontists are full time.
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Kevin Mosher:
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Correct because we do surgeries in the morning. We don't do surgeries in the afternoon. We'll do some singles and multiples, but we do the all on four cases in the morning. Then patients are recovering in the afternoon and our labs are making their teeth and then their teeth are put on later in the afternoon and they go home.
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Howard Farran:
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I think Olly Jensen is one of the finest men I've ever met. He's just an amazing man.
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Kevin Mosher:
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He is.
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Howard Farran:
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He's the one who tells dentists the best implant [inaudible 00:41:51] is just go down to your local Clearchoice Center and hang out there. Watch those guys. He's a big believer in that.
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Kevin Mosher:
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Two things. I'm going to lunch with Olly as soon as we're done. He is a great guy. The second thing is that a lot of clinicians who I knew at Nobel who were skeptical of Clearchoice and what Clearchoice does, we've invited them in and they do walk away quite impressed. Even very accomplished surgeons who can do all on fours, they remark at how well oiled the machine is at Clearchoice because when you are doing two to three arches every single day, the staff, everybody, there's no down time. They know exactly what they are doing. It's a well choreographed group of folks that do a tremendous service for the patient.
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Howard Farran:
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Anytime anybody emails me about this show, they're always a kid, they're either a junior or senior in dental school or they've been out for five years and they're just devouring these podcasts every day, but I always like to remind them that I'm 53. When I was in dental school '84 to '87, the people who were doing implants, oral surgeons were considered nuts, crazy, barbarics. They were sticking [inaudible 00:43:05] and [inaudible 00:43:05]. When I moved into Phoenix, Arizona, a guy across the street from me was doing these and he had an airplane and he flew to Phoenix, Albuquerque, whatever. He was having amazing success rates, but all the locals just- they thought he should have his license taken away. It really has come a long way. Some of those legends, some of those guys that were doing the most amazing cases like you did, the first time they had one case fail, the board was just waiting for them and took their license away. Those guys were pioneers. You just always see it in dentistry.
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Endodontists, they always did every appointment in two steps all throughout the '50s and '60s and '70s and the first guy that said, "Let's just do it in one appointment," it's like, "Heresy! Kill that guy!" Now you see implants probably in their medium term the longest implant was the best. Now you see people saying, "It's just surface area. It can be short and fat. It doesn't have to be long." Everything's changed so much.
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I want to ask you, you are so smart, Naval Academy, president of Nobel Biocare, CEO of [inaudible 00:44:07], CEO of Clearchoice, a common question that dentists are always asking me is if you look at the ADA statistics, which is done by a PhD economist, they have great statistics, great sample size, show their math, their standard deviations, general dentist median income peaked a decade ago in 2005 at $225,000 a year net take home. Over the next decade, it slid 4500 bucks a year and now it's down to 175, so they've gone from making 225 in 2005 to 175 in 2015 and the trajectory doesn't look like it's changing. Why do you think general dentists have lost $45,000 of net income over the last decade and do you see it continuing?
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Kevin Mosher:
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It's a great question. I think that-
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Howard Farran:
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All my questions are great.
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Kevin Mosher:
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I've listened to that economist from the ADA. He's a fascinating guy. I can't remember his name. What the economist will also tell you is that dentistry for the last decade has been ... it's pretty much been flat, but if you look at it more granular, what you see is that pediatric dentistry is growing and dentistry that's oriented towards the elderly is growing, so it's that middle, the typical healthy adult, early 20s to late 40s that they're going less and less to the dentist. I think that's the bread and butter for most dentists is that demographic. I really can't speak to competition, are there more dentists out there than there were.
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My sense is there probably are, mainly not because dental schools are graduating more, but because folks are retiring later, but I think they're chasing fewer opportunities. That competition breeds reduction in some cases or price competitiveness. I think that less production is less income for the dentist because they pay everyone else and, at the end of the day, what is left over is what they take home. I think it's because that middle demographic is- Dentistry is not flat. If you look at that middle demographic, it's down. There's less production, less income for dentists. I think that's the biggest problem.
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The whole cosmetic boom, that did its thing. Now everyone's a cosmetic dentist, so you can't differentiate that way. You've got this shrinking pool of patients that will drive production and everybody looks the same to them. I'm not saying they are all the same, but they look the same. If you want cosmetic dentistry, you can pretty much go anywhere these days. I think that's what it is. I think it's demographics. It really took hold around that 2008 recession. As we know now, the recession started before 2008.
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Howard Farran:
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What was the DSO market penetration would you guess in 2005 versus 2015?
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Kevin Mosher:
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In '15 I'm going to guess and, gosh, I know these numbers because I go to the meetings, but you always forget, is it future looking. I would say in '15, probably you're in the range of about 20% DSO. If it's going to be off a little bit, it's just going to be a tad lower, like 18 to 20%. In 2005, it was probably, gosh, it was probably more like, I'd say, 7 or 8. It's a trend that's really taking-
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Howard Farran:
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When you say 20% in 2015 are DSO, do you mean 20% are in group practice or do you mean actually working for a dental services organization that has multiple locations?
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Kevin Mosher:
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The latter. The latter.
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Howard Farran:
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The multiple. Where do you think that number will be in 10 years, in 2025?
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Kevin Mosher:
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I think it's going to be in the high 30s.
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Howard Farran:
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Where do you think it will max?
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Kevin Mosher:
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I think ... and the high 30s, that's speculation. I think it becomes the norm, I really do. When you think about it, the marketplace wrings out inefficiency and if there's a solution to inefficiency ... and it's not a bad thing. When you look at the average dental school student these days, they came out hundreds of thousands of dollars in debt. Dental practices are very technology driven these days, so it's very expensive to open a new practice. They've got that double whammy of, "How do I borrow to open a new practice," which is much more expensive than it was when you opened your own practice, probably, and then they're servicing a lot of school debt. DSOs offer a solution to that. Generally what's interesting with a DSO, the work quality life balance tends to be better and the income tends to be higher. I feel like those are all pretty powerful factors or attributes of a DSO.
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Howard Farran:
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One of the smartest people I ever met was my son Greg. He told me that it's going to max at 50% because he goes back to the lawyers who start consolidating first. The problem when you have highly educated employees with eight to ten years of college, it's like herding cats. When you look at a very large employer like Walmart, they're mostly high school graduates, but in law firms, about half are in a big firm and the other half couldn't handle the politics, they're too smart to take orders or follow other people. I almost think it's going to be like lawyers. I think DSOs are going to get half and then the other half are going to be these boutique specialists by dentists whose personalities are like, "I'm not going to go and ..." You probably can't get all of the dentists on Dental Town to agree that today is Tuesday.
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Kevin Mosher:
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I think there's a point there. I think that we should consider your question just prior to this is why are incomes declining. There are only two ways to improve your income as a dentist: increase production or decrease costs. If production, by definition, is constant, let's just say it's flat total aggregate production, then you got to decrease your costs and there's no better way to do that than to centralize many of the functions, consolidate purchasing to an entity that has much bigger purchasing power. That's what DSOs offer. They offer the ability to lower the cost end a bit. Yeah, so 50%, who knows? I know that-
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Howard Farran:
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I also think that it's humorous, if not downright- it's just crazy on Dental Town, the same dentists that complain the most about the DSOs and just think they're this bad, evil force, they're just bad, are the same ones telling everybody they should have a $150,000 [inaudible 00:51:08] machine, a $100,000 CBCT, an $80,000 [inaudible 00:51:12] laser. That's a big part of the equation. A lot of healthcare economists claim that the consolidation of the physicians, because there's 950,000, almost a million physicians in the United States, only 150,000 dentists, what started the consolidation was actually high tech equipment, like the CAT scan, the MRI, all these high tech things that it just didn't make sense- How is one OB/GYN going to afford this machine, but if we bought it and shared it with half a dozen, it makes sense. It's the high tech.
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I always think the bottom line is what's best for the consumer and I think what's best for the consumer is when there's 168 hours in a week and I tell everybody that, in Phoenix, Arizona on a Sunday, you're a lot better off getting stuck on a mountain because you know the fire department's working, they'll get you, you're a lot better off getting in a car wreck because you know the ambulance is going to get you and take you to the hospital, but gosh darn forget it if you have a toothache in Phoenix, Arizona, with 3800 dentist, you'd be more likely to see an alien or god before you found a dentist that would treat your toothache.
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Kevin Mosher:
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It's interesting, too, technology, when you think of the history of the medical profession and medical care, the wealthy never went to hospitals. Hospitals were for the indigent. You know what it was that caused the wealthy to start going to hospitals? It was technology and it was not high technology. It was ether. It was anesthesia. It was an explosive hazard in homes. They had to consolidate it to hospitals and that's when the trend started to shift it the other way. When you look at consolidation, and I think that beyond 50%, I would agree with Greg, at that point it's wild speculation, but I think 50% is definitely in the works, but I think that the trend is in place and I think that it's certainly already happening in a big way on the medical side and medical doctors. The days of solo practitioning medical doctors are numbered because of the affordable care act.
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Howard Farran:
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I'm sorry if our American Dental Association Chief Economist is listening to this. The reason you and I don't say his name is because that's a tough name to pronounce. His first name is Marko, M-A-R-K-O, but his last name is V-U-J-I-V-I-C-
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Kevin Mosher:
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Vujivic or something like that.
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Howard Farran:
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Vujivic?
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Kevin Mosher:
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Something like that. I remember that now that you've said it-
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Howard Farran:
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Is that Eastern European, maybe? Something like that?
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Kevin Mosher:
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I think so. He's a great person to listen to, though.
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Howard Farran:
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He's an amazing man.
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Kevin Mosher:
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He's one of these guys that's super intelligent, they all are, but most of them can't be entertaining, as well, and he's entertaining to listen to.
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Howard Farran:
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I want to ask you- another question I want to get into. Let me pull it up. I sent this. Back in the day, a reoccurring problem is, so back in the day, Reader's Digest who, when I grew up in Kansas every mom and dad and grandpa and grandma had a Reader's Digest sitting on their nightstand, so when they came out with that article how dentists rip us off, when all the dentists on Dental Town started saying, "That's horrible journalism," it's like, the Reader's Digest isn't horrible journalism. I was the first one to say to my homies that, "No, listen to these guys. What they're saying is so true." This journalist, he went and he took x-rays and study models to a bunch of different dentists and every single treatment plan was different. In fact, the following location of dentists, six dentists listed through the exchange, 11 were crowns, including four dentists who thought he needed 21 or more. The cost estimates were 3,000, 2500, 1900, 1952, 3400, all the way to 29,850.
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I think the thing I always wonder about a big chain like Clearchoice Dental Centers for the consumer in general, if you patient in Phoenix went to 10 different dentists, oral surgeons and periodontists to get a consultation about implants, if they went to 10 different doctors in any one of your markets, do you know how many treatment plans they would get?
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Kevin Mosher:
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Going to our centers?
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Howard Farran:
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No, I'm talking about the patient.
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Kevin Mosher:
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They would get many, many, absolutely.
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Howard Farran:
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They would get 10. In fact, they would get more than 10. If they went to 10 doctors, they would probably get 20 because half the doctors would give them three treatment plans. How does your business mind wrestle around the fact that, when I go to the store and get a gallon of milk and an iPhone and a gallon of gas versus when you're going to dentists and every single treatment plan is different, do you ever wonder to yourself, "Is this science or art or are these guys crazy?" How do you wrestle with that? The other thing with these corporate chains, how would Heartland standardize a diagnosis and treatment plan.
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It's the same thing with law. That's why I always go back to law firms. You notice here's the Constitution. It's 275 years old. None of the words have changed. Every one of those lawyers on the Supreme Court's got eight years of college. They're looking at an exact law with the exact words and most every decision is five to four. They just completely disagree. When's the last time you saw a Supreme Court decision that was nine to zero?
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That's the way it is on a treatment plan. You present the x-rays, the study models to these nine Supreme Court dentists and holy moley, it's all over the field. What's the consumer to do?
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Kevin Mosher:
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I think we have to recognize we're dealing with human beings. Particularly when it comes to healthcare, there's always going to be variations in a diagnosis. I think that what you're speaking to, though, is part of the problem with a cottage industry where you have 120,000 dentists and I don't know how many solo practices. What they lose in solo practice is influence from colleagues. When you think about hospitals, I spent a lot of time in the hospital market, hospitals go through their [inaudible 00:57:19] inspection, it's a joint committee for inspection. I can't remember exactly what the acronym stands for, but every hospital goes through this accreditation process and they look at standards of care and ways of treatment and so forth, so you at least standardize somewhat. Now, every patient is going to present a little differently and you'll have variations, but you're going to have a much tighter dither in an accredited institution where colleagues are interfacing with each other. When you're solo, you don't have that benefit.
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I think the DSO, what we do is you'll get variations in treatment plans, I'm sure, but what we do is we share best practices and the clinicians love that. We have a doctors' conference. We have our semiannual doctors' conference next week. The doctors get together and they talk about cases and they consider treatment planning options. We have a mentoring program within the network where clinicians interface with each other. We have a clinical advisory board.
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We have processes for sharing best practices and I think that that benefits the consumer of healthcare is that you are much more likely to get a higher standard and a standard of care than if you go with somebody who's solo and isn't interfacing with colleagues and professionals on a regular basis.
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Howard Farran:
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On a final note, can I give you my best marketing advice for you, which you are not asking for and I could've not have gotten into the Naval Academy, so take it with a grain of salt, is that we started Dental Town Magazine in '94. In '98, we started a website message board. I'm living in Phoenix, so I saw this University of Phoenix online popping up, so in 2004, we started online CE courses. Then we came out with the app. We put up 350 courses on your iPhone and they've been viewed over half a million times. These dentists are like, "In the old day, you'd shut down your dental office for $5,000, fly to another city, take a course, leave in the afternoon." It's just faster, easier, higher quality.
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Your Clearchoice and your relationship with implant companies, there's so much online CE you have. I think Clearchoice should start putting up online CE explaining what you do. Instead of other people talking about what all on four is, you should be the leader of that message and then show them how they've got skin in the game, how they can work with a Clearchoice center and no one, I cannot believe it's 2016, you can't teach a kid implant surgery from A to Z and they need to know if from A to Z so they can believe in it and treatment plan it.
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I remember, I'll go back in my day, I was a very late referrer to sinus lifts because everything I'd heard about it was so bad. It was a long time before, it was probably 1995 before I finally believed that sinus lift, this isn't bat shit crazy. This is a real procedure.
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I'm thinking this would be a 25 to 50 hour module if you stared with diagnosing and treatment planning and [inaudible 01:00:33] a sinus lift, over dentures, all on four. Then the message being from your Clearchoice doctors and, "Hey, I'm in Tampa. You got a patient, come on, let's do lunch." I think it would be phenomenal marketing. I think it would be the best marketing you could do.
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Kevin Mosher:
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I think that you raise a good point. Two things, we have the content because we use it to onboard doctors when they come in. We load it all on iPads and they can use that as part of their onboarding. We have the content. The second thing is an agreed upon value in this network is a passion for learning, so those both fit with what you're suggesting. I think it's a good idea, actually.
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Howard Farran:
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I'm howard@dentaltown.com and the guy that runs CE is Howard Goldstein in Bethlehem, Pennsylvania and his email is hogo@dentaltown.com. Send us an email because I meet dentists all the time that they say all they know about all on four is that they assume it's like a table. It's got four legs. They just know it's four implants. They don't know any more than that and a lot of them have seen the Clearchoice advertisements, but have never actually gotten in their car and driven down there and walked the center and all that. I think you guys are amazing. Like I say, tell Olly Jensen that I think the world of him. I think the world of Clearchoice.
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The reason I think the world of Clearchoice is because I think every dental office, I think their mission statement would be to create a dental office that you would want you to be a patient at or your children to be a patient at or your grandchildren to be a patient at. I think what you guys are doing is you're putting the patient first and you're doing a phenomenal job. I've seen so many of your patients and customers in Phoenix and, like I say, your commercials are rising tides for everyone. I just think what you're doing is phenomenally well.
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The only thing I don't like about it is your hair is so good. I hope they're watching this on iTunes and not YouTube or Dental Town because I never felt so bald in my life until I've been staring at you for the last hour. Thanks for giving me an hour-
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Kevin Mosher:
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Hank you.
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Howard Farran:
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Of your time. I know you've got to be one of the busiest men in dentistry. I really appreciate your time.
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Kevin Mosher:
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Thank you. I enjoyed it.
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Howard Farran:
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If any of your Clearchoice oral surgeons or prosthodontists want to come back on, send them a group email that says I would love it. REC implants and endodontics, you just can't give them enough information on implants and endodontics and you've got so many oral surgeons and prosthodontists, send them a group email. If anybody wants to sit down for an hour and talk teeth, I'd love to interview them.
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Kevin Mosher:
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Great. Well, thank you very much, Howard, I enjoyed the time together, so-
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Howard Farran:
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I'll get out of here and-
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Kevin Mosher:
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It was a lot of fun
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Howard Farran:
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Shave that head. Have a great day.
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Kevin Mosher:
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All right, you, too-
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