Pete Vera, Exit Algorithms: Welcome to Exit Algorithms, the podcast where we decode what it really takes to unlock growth, streamline operations, and prepare your business for a high-value exit. I'm your host, Pete Vera, and today I'm joined by Alex Fernandez. Alex is a seasoned healthcare executive with over 30 years of experience in leading and growing multi-site physician practice management companies. He's the CEO Synergy Orthopedic Specialists, the largest. private orthopedic medical group in San Diego, California, with over fifty providers, surgeons, and specialists across fifteen locations, fives five physical therapy sites, MRI Center, and Amulatory Surgery Center. Alex, excited to have you here today. Welcome to the podcast.
ALEX FERNANDEZ: Pete, thank you. Pleasure, my pleasure for you having me here. ⁓ you know, like we talked in past, been an interesting and love what you've been doing as well and what you're with the world, around ⁓ you know, basically growing your business and and creating value in order to create an exit. So, you know, my background, I you know, I personally I I started in the front desk. I ⁓ you know, I was going to school and I wasn't really thinking I was my parents are not doctors. I'm not a doctor or anything like that. I'm a business guy, so I went to business school and but I needed a part-time job. So in the nineties, I just got a job doing at the front desk in a in a doctor's office. And You know, over the years I just learned the the intricacies of of running and operating a a successful medical practice. whether it's revenue cycle management or managing your expenses and accounting, recruitment, company culture, and basically creating something where I you know, I always thought I always saw the physicians as you know, they're super smart people and they great at medicine, but they never d they don't teach business. They very few, I mean I've felt I've dealt with very smart executive physicians, but the majority are really good at what they do. They heal people, they get them back, you know, whether it's orthopedics, they get you back running or walking. if it's, you know, gastroenterology, they cure your cancers or they make you feel better because you might have ulcers or whatever. If you're an OB, you're delivering babies. You know, they they really good at what they do. But when it comes to growing their business, it's very similar to any other industry where it's kind of small. It's usually one doctor or two or three because they bring in some partners that augment the the relationship and the opportunity for revenue. And then they're always trying to figure out how to reduce costs. So they hire an office manager, and that person, in some cases, somebody maybe that grew up in the company, similar to what I did, different from me. I do have an MBA from University of Miami and and and I've you know run hundred million dollar businesses. But when you start at the beginning, it's it's just the basic platform of growing an organization, creating a culture. creating a business that can run without you looking for ancillary revenue streams or ancillary business opportunities that you can plug in or or bolt onto the business so that the business can continue growing and you can go on vacation for three weeks to Europe and nothing falls apart.
Pete Vera, Exit Algorithms: Yeah. ⁓ exactly. That's the the secret sauce. I I I think we'll probably get into that a little bit ⁓ more in detail later. but yeah, you were talking on the pre-show about your your background in PE backed companies. I do you mind sharing a bit about that, you know, your first experience being CEO and then all the that journey to to eventually exit?
ALEX FERNANDEZ: Yeah, yeah. Yeah, so I started with the the journey there, particularly with Gastro Health. Gastro Health was a group of several medical businesses or doctors that came together basically. three groups that knew each other, they say, hey, we have to like we merge and we form one bigger entity, we'll be able have leverage around cost, around revenue, around marketing, around branding, et cetera. We'll be able to put our monies together and through economies to scale, be able to invest in in our opportunity in our business to generate more wealth for us, the doctors, the shareholders. and then over the years, when I came on board, what we did is we just continue growing. particularly growing through a lot of mergers, small acquisitions, hiring more people, hiring more doctors, and just continue growing the business. And when it got to a a point of, you know, which I think, you know, for for private equity, there's that five to ten million dollar magic number that that they're looking for. Sometimes they do go in and and and buy businesses that are smaller than in the million two million range in in regards to earnings, but the really the sweet spot is above five. If five to ten is is great. And if you do 10 to 15, there's a lot of other opportunities if you're in the 15, 20, 30 million dollar eBIT business. But if you're in the smaller scale, the key is growing the business and adding and bolting on, like I mentioned before, some ancillary revenue streams that can augment the business outside of from what the in this case the what the physician does. so the the grew to about seven sixty of revenue, we're about sixty of revenue close to 10 at Vida back then. Back then the values were going around 10 times ⁓ multiples of of earnings. So it was an over $100 million deal. to to get that platform done and then that that business has exited again and that business close sold to close to a billion dollars in ⁓ the second time around second what they call the second bite at the Apple. so I think the key is more around a practice if if if a practice is a job that you own, or is it a platform that that runs without you, I think that's really the the big clip, you know, the big idea. A a practice is a job you own, a platform runs without you. so, you know, do you wanna buy something that, you know, some some people nowadays are talking about buying ⁓ businesses are AI resilient, you know, buy a laundromat, buy a, ⁓ you you know The guy that does A HVAC work, et cetera. But if you buy a business like that, then the the bigger question is, is the business gonna be able to run without you? Or you're the guy that you're an HVAC guy and then just get into that business. You're you're a a trainer and you buy a gym and you're just basically buying your a job. ⁓ so you have to figure out a way to scale the business up so that you can, you know, sit back and look at it from a capitalist perspective as an like you're also an investor, not just the day laborer that's ⁓ the wheel and making things happen.
Pete Vera, Exit Algorithms: Yeah. Yeah, definitely. Wow. and the deal specifics, do do you did you ⁓ any rolled over equity in that? in that initial ⁓ okay. you did get second battered apple when they exited again. Yeah. Did you do you recommend that that structure as a you know as a CEO of a company? Did you did you like that? you know, this how was it ⁓ how was that transaction?
ALEX FERNANDEZ: Yeah, yeah, yes. Yeah, yeah, yes. Yeah, of course. But I I I yeah, no sorry, f fin finish the the the question. I I I didn't mean to
Pete Vera, Exit Algorithms: No, yeah, yeah, I was just d any any feedback on how that transaction ⁓ for you and and did was the were happy with the the at the outcome of the the sale?
ALEX FERNANDEZ: Yes, for sure. Yes, I was happy with the with the exit. I will frame it differently. I think from an owner operator, and in this case, I was a partner operator is the way I would look at it, because there were multiple partners in the deal. but as an owner operator, whether you're a family business that's growing and then you figure out you might want to retire or I might want to ⁓ do something different because maybe my kids are not gonna take over or somebody in the business is not gonna take over or they might not have the capital to be able to buy the the the organization. I think the key is more around structuring ⁓ enterprise in a way that if you are gonna stay on board as a CEO for a period of time, you really with your lawyer and with counsel kind of figure out what the mechanics of that looks like. Whether you're Hey, I sold the business. I'm gonna give you 90 days and I'm out. Or I'm gonna sold the business, but I expect to be here for the next 10 years. And what do the mechanics look like that? Because I think know, I I've done it where I th I feel my sweet spot is getting into these smaller medical practices, putting them together, bolting them on, growing them to a certain level, doing an exit, you bolting them again, doing and in and doing that where I the people that when I left, the people that replaced my role are people that have run much bigger organizations that might not necessarily have the skill sets that I have to bolt it on, to make you know, to start from small. And I think that there's different stages in any business and my my sweet spot, it's the smaller businesses and growing them to a point that they can exit to an organization. Personally I've done it in healthcare, but I I I probably do this in any other industry as well. The the mechanics, the the KPIs, the the way that the business works is they're all the same. it's just, you know, growing a business that that that can generate and do more than what you personally are gonna put into it. I I always say that, you know, the the idea is, you know, you know, i every business or the same bus same EBITDA, different multiples, and the structure is why. You know, w why is why is is are you gonna get, even though you have let's say two million dollars worth of EBITDA, gonna get a six multiple where somebody else has two million dollars EBITDA and gets eight. People tend to focus more on, ⁓ well this guy got paid more than that. Well the question is why? Why did they get paid more? What did they do?
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: That they they leverage their organization. Maybe they have better margins. Maybe they can grow their business setup for growth. They don't have to bring in a CFO because they already brought you already have the team in place. the investment organization doesn't have to put as much into the the business after they acquire it in order to grow it and or are you gonna or are they acquiring you because you're all basically a a something that they're gonna add ⁓ on tuck into the enterprise that are. already exists. There might be a b larger private equity firm and I did I've done this as well. I did or thirty something transactions when I was looking at smaller medical practices that I wanted to acquire or that I acquired in order to bolt in or tuck into our enterprise business in order for the bigger business to be worth more.
Pete Vera, Exit Algorithms: Yeah. Yeah. What are some of those big ticket items would you say that, you know, that command a higher multiple, comparing two b businesses with the same EBITDA?
ALEX FERNANDEZ: Yeah, I I it starts out well, I would say in in healthcare or in medical practices, there's typically a lot of doctors. Especially when you get to larger numbers, there's that means that there's a lot of people involved in the in the in the business as owners or shareholders. ⁓ currently the business I'm with has providers, people that provide care. Some are surgeons, some are physical therapists, some are radiologists, anesthesiologists, et cetera. But there's a smaller group of people that are owners, but I still have two dozen owners in the business. So want or you know the owners, the shareholders are thinking, well, I think this is the right strategy or this is where we need to go or this is what need to do. And I think the key in in growing a business is making sure that everybody in the business, owners and non-owners, are sharing the same vision, that we're all in the same boat, that we're all rowing in the same direction, that we're all showing the same flag. you you wanna make sure I've I've owned, for example, real estate businesses as well. I'm I'm a real estate broker in Florida. And hard part is when, you know, ⁓ you have a real estate broker that's really good and he wants to like have his own brand and create his own thing, but he doesn't want to own the business and he doesn't want to be a broker. He doesn't want to go through the the complexities and the the the things that ha have to do that. You have to make sure everybody in your team ⁓ is your team. And they're all seeing the same vision, same growth. So I would start with with the the basic idea that the organization ha and everybody in it has to be going in the same direction, has to have the the same idea, whether that's growth, whether that's growth through sales, growth through acquisitions, integration, etc. And then the next part I would say that the bridge a significant amount of opportunity for a higher multiple is your team. Are The one person that does it all, CEO, C O O, CFO, C marketing, you're you're everybody. But on top of that, you don't even have anybody under you. Like the next level under you is the workers. There's no management team. there's no whatever. Granted, I mean, we know that with AI, it's interesting now. You have like hundred million dollar businesses, exits that are that are being acquired, and there's like two people in it because you have AI running it. So I think that's a leverage too. If you are able to utilize AI in a way that you can grow your business with a lot of with a with little overhead, I think that that's also important. But more importantly, it's I think it starts out with vision, and the whole organization going in in the same direction. And then finally the idea that have a team that you've built that is more of a platform than The opportunity to be a tuck in. So if you can build a platform and you have the right amount of EBITDA, you'll be able to get a much greater multiplier on your earnings.
Pete Vera, Exit Algorithms: Yeah. ⁓ that that's great advice. yeah, and I I think it's really useful for listeners to to hear the a buyer's perspective, you know, so they can shape their their business to be attractive to, you know, whatever buyer they want. when when does, you know, from a acquisition standpoint, when does it make more sense to grow via acquisition than ⁓ than organic growth?
ALEX FERNANDEZ: I think it a lot of it has to do with your current earnings and leverage that you can get from a an institution, whether it's banking or you know, leasing or or whatever institution, your SBA, wh whatever you're doing. Because if you're a single owner and you you have, I don't know, a lawnmower business. And you're the guy that cuts the lawn, it's gonna be very hard for you to go in and buy another lawnmower business. You might buy another route, which means you're gonna work more, but doesn't necessarily mean that you're gonna be able to create bigger wealth, you know, through an acquisition. but on the other hand, if you're the guy and you have 10 guys cutting grass and you've been growing that business and you have a certain amount of earnings or eBa, you know, leftover income, and you can use that to go to SBA or go to a bank or or say, hey, I'm gonna, you know, buy this small business, they're worth another million dollars. And, you know, I I'm gonna come up with, you know, 20, 30% of it cash and I need to borrow 70%. And you have people in your team, whether accountants, lawyers, people that that can back you up, consultants that can back you up and and help you frame the business model of why this is important. And why you should go ahead and and do the next the next step by by building buying the next business, then that probably makes sense. I mean it it ⁓ on the other hand, if the business ⁓ that same business it's stayed away, that might not necessarily be a d a good business, a good business idea. On the other hand, if it's contiguous to your market and if you are in one county and you maybe are going to another county or if you're one city and you're doing another city within the county, that probably even makes more sense because it's still within an an area that you can you can reach, you can manage, you can provide good customer service. if something goes wrong, you can go visit your client and and talk to them and find out why they're not happy and how you can make it better and so on. But if you're trying to grow the business in a particular market, And then you go to another market, that's great. You go to another market, that's great. But then the next leap is like, ⁓ I'm gonna go from Florida to Chicago. why? ⁓ what the hell is that all about? You know, why why buy another business that's literally thousand miles away that you have to get on a plane and and spend three hours? Now you're you're gonna dilute the business you're in unless it's a really great opportunity over there and you have a really strong team that can back you up. In other words, now you the business at a point that you can leave it for two, three months and to start and take over and bring your mission, vision and ideas to this other state, that might make sense. But I think if you're in a particular area and you and there's still a lot of growth in markets around you, why not just continue growing in the market that you're in? So I I I think it's two prong. First you have have the skill sets, number two money, and then number three, the opportunities that are nearby versus opportunities that are really far away.
Pete Vera, Exit Algorithms: Yeah. ⁓ yeah. All all that that makes sense. All that that all goes into it and timing is is a big element there too. you know, I I read a statistic recently that said over percent of deals fall through during due I I'm curious to know from your experience of a lot of deals, you ha what are some of the common causes of deals going sideways?
ALEX FERNANDEZ: Yeah. Yeah, I I would say that I I personally haven't had a lot of deals fall through due diligence. And I think a lot of it is because I do a lot of pre-du diligence before acquisition. And I think so I I I always look at it as like when you're gonna enter in a transaction like this, it's almost like you have to date a lot. And you get ⁓ And then you get married. I think a lot of organizations just get married. ⁓ so I th yeah, so I think that you know the key is when I when I started talking to a medical group that I'm looking to to bring on board, I'm looking for what are pain points? You know, is it that they just want money? If they just want money, it's probably the wrong the wrong deal.
Pete Vera, Exit Algorithms: Yeah. Throw the ring on.
ALEX FERNANDEZ: On the other hand, if they have pain around opportunities that I can bring They leverage success, something that's gonna, you know, in in our business in healthcare might be contractor rates. We we have we we get a a state rate that's ⁓ negotiated by an insurance company, let's say United. So if United pays you dollar for dollar, you know, well that's great. But if ⁓ pays me dollar fifty per dollar, well, I have a really good strong proposition that if I go in and bring you on board, even if there is a, you know, even if there's some earnings, there might be some idea of a increased revenue for the person selling. So there I've done deals where even though the doctors, for all intent and purposes, are selling and we're making earnings out of the business. they actually make more money. So it's like the the I would say the multiple wasn't times three or that. The multiple was infinity because I actually paid you and you're making more money than when you before after you sold. So th you know that there's really not a multiple of losses. There's a multiple of earnings that's positive, which a significant amount of opportunity. So it might be that. It might be that, you know, somebody's retiring in the group and the the lead doctor is going to retire and he's worried about he's the one that's been running it. The other three doctors in the group are not very savvy around business or marketing or, you know, billing, which is revenue cycle management, how we how we get paid by insurance companies. So therefore, they might need somebody to come in with professional management to take over the business to help them run the business moving forward. So if you say, I'm going to give you better rates, going to run your business, you can focus on providing medical care, you're still going to be a shareholder, you're going to make more money than you did before. It's a win-win for everybody. But if the idea is, hey, we're fantastic, we're a magnificent business, we don't have anything wrong with us. And we making $500,000 worth of earnings. don't know. What what am I gonna do? ⁓ you what? You know, and then you don't wanna change. There's nothing wrong with you. You just want me to pay you f you know, you make five hundred thousand dollars, you want me to pay you, let's say, five times earning, I'm gonna pay you two point five million dollars, and you go away. so the business you buy it and the business walks out the door with retirement. So and then to replace it, you have to find doctors. And in the healthcare business, much harder. to replace the talent than there is in ⁓ other industries where, you know, again, if you're HVAC business, you can hire more techs. If you're in the I don't know, you know, supply or accounting, I mean the the more professional the business is the harder it's to replace. I've had friends that have invested in in CPA and I'm like, you know, the C P A leaves, the business just walk out the door and you get, you know, you get holding
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: And it's not gonna be that easy to go ahead and replace ⁓ with another CPA. You can replace somebody that's that can do the work, but you can replace somebody that can manage the business or or bring business in, et cetera. So
Pete Vera, Exit Algorithms: Mm. Yeah. And that touches on a a theme you mentioned earlier too, building a the business to be able to run without the owner. do you think business owners should think about building a building that management layer you know, a a few years out at least before before considering a sale?
ALEX FERNANDEZ: Yeah, I think it's critical. particularly there's a lot of businesses. I grew up in a in a retail business. My parents had bridal stores. They have multiple stores, but it was my dad and my mom. My dad and my mom were the you know, typical mom and pop organization, but we have four or five stores. I mean they they had a significant footprint in a mark in a particular market area. but they never wanted to go ahead and and bring in other talent. They felt like, well, you know, I'll talk to my CPA about taxes, or talk to my lawyer about, you know, a transaction or a lease. But they didn't want to bring in any level. Funny enough, my youngest brother was the one that was really interested in the business. He liked photography and the bridal business was ⁓ included photography, et cetera. And And their exit, it was my brother. My brother's the one that ended up buying the the business and my my father passed away years ago and my mom is the one that stayed behind working with him and provided a great opportunity. So I think that there's if the business can ⁓ generate bring in talent, whether it's and I would say a couple years before, if you're thinking of exiting today, you pr probably should have thought about ha bringing people and bringing some talent years ago, you know, three, four, five years before. And at some point in time you have to bring in you have to build the infrastructure where if you can go away for a month on vacation and just routinely call and say, Hey, how are things going? And you look at the computer and you see either whether it's a CRM or you're looking at your your ERP system, you're looking at your computer or bank QuickBooks, you know, to put it ⁓ more more explicitly, you're looking at QuickBooks and sales are going through, then the business is doing well. And yeah, maybe it dipped a little bit because there are some things that you do personally as a business owner. But if the business is doing right relatively well or even succeeding while you're not there, that's the business I would like to buy.
Pete Vera, Exit Algorithms: Yeah, definitely. An asset that runs without you know, runs by itself, you're gonna get a lot lot higher multiple from that.
ALEX FERNANDEZ: Yes. Correct. Correct.
Pete Vera, Exit Algorithms: yeah, great, Alex. And I wanted to make sure we touch a bit about AI. I'd love to hear your perspective. how is it affecting your industries the most and ⁓ and are you using it personally?
ALEX FERNANDEZ: personally I'm still dabbling. I I will say this. I'm primarily, you know, using it to develop financial statistical ⁓ projections, know, things that would take my analyst to provide to me. they they you they still the analysts still run ⁓ all the reports and per and per present them to me. But now I can th those reports and generate, you know Probably I think it's more things that I already know, but it kinda puts them in a perspective. It's like, hey, ⁓ the you know, strength and weaknesses of the business right now, you know, where are the opportunities, where are the areas that I should focus on? So that's primarily w where I'm where I'm doing but I'm I'm being deliberate and disciplined about the AI. I'm not deploying it where you know what I can't measure or govern. I'm not using it to like let's say code new software. I'm not a coder. But I know people are doing that or or I hear co working, having basically an assistant that does a lot of work. But I I we are starting to dabble around the AI, Basically answering the phone. Instead of the prompt being press one for this, two for that, three for that, we have an AI agent that kind of talks you through. In particular, we're using it for two areas. capture, for example, in doctors' offices, it's hard to get through the phone. So half of the time you can't get through the phone. Well, I what if I could answer every single phone call? And if all you want to do is cancel, why can't I just go ahead and cancel the appointment? So I can have the AI cancel the appointment and have an open slot and then immediately text maybe people that are on a waiting list. us to come in sooner and say, hey, we have this open slot. Do you want it? And you know, first come, first serve. Whoever gets, you know, whoever says yes first gets the appointment and I get people in the door and I don't have any open slots in my schedule, which I think that's extreme extremely important to to a doctor's practice. we're also looking it in in regards to payment. So if you just want you got a bill Typically you're like, why do I hold forty bucks? I thought I I paid everything. And then the you ask the question and the AI could come back and say, the forty dollars was in addition to your copay because you have a deductible outside of your copay for $300 and you've met it to $120 and $40 is what's left over. And you're like, okay, would you like to pay the bill now? And they're like, Yes. And then it sends you a text and you put in your credit card payment information and say yes.
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: And the payment gets done and the whole loop gets closed. So I think that there's for sure opportunities where I'm not looking at it from a per perspective of reducing staff. I'm looking at it more from a perspective of expanding my my my staff or my capabilities from my team, given that ⁓ some point in time I don't have enough money to hire a hundred more people. I can only you know, so at some point in time i the the idea is how can I leverage the AI talkment and generate more profit or more revenue from what you already have without having to scale back. I do feel that there are some jobs and I see it already, there's some jobs that in the future are gonna change, no different than when, you know, I started this industry 30 years ago and I was doing paper claims. I literally you fill out the the claims that on paper and send them out to the insurance company in the mail. And then later on you started using a computer and filling out the information on the computer. And then it literally I remember dialogue mode and going whatever. And then basically sending out the information to to Medicare and the carriers and the and technology continues to evolve. So I think staffs will to evolve, people will have to evolve in your organization. And as CEO, I think it's my job to make sure that I'm giving them the tools, the education, the training to help them get there. so I I I feel like in the future there will be somebody that's a medical assistant that takes care of let's say prescription refills, might have a couple different agents that do prescription refills or a nurse that does that and and they kind of like manage that work with multiple people. so and then another will do else. I I think in healthcare it's gonna be very hard to replace AI, particularly because we have to touch people. Even when we were doing telemedicine during the 2020, 22 or during COVID, we were doing a lot of virtual visits. And think even that over time scale back because people wanna see, they wanna touch their doctor. They want the doctor wants to touch them. They're like if you're in in dermatology, we wanna check your skin. If you're in orthopedics, we your knee hurts. I need to touch your knee to see where it hurts. Your your gastroenterologist, you tell me, well, I have my belly hurts. Like they have to literally push on your stomach to make sure, you know, they they know where what hurts you, what ails you in order to figure out what the next thing is. I do he I do see and hear from our doctors that patients come in with like, my AAI told me that I need to do this. I'm like, or my recovery was that I'm like, well, I'm not sure that it's a hundred percent wrong, but this is what I think you should be doing. I am your doctor. so I I I do feel like in some areas it's gonna evolve much faster than others. but I think there's a lot of jobs, particularly in healthcare in a lot of industry that that require physical work, that it's that's not go away. I mean, I just don't I don't see the AI picking the watermelons off the But maybe with and robotics, maybe we'll do some of that. But I I think we're probably sometime away. Not not thirty or forty years away, but But not tomorrow either. Somewhere in the middle.
Pete Vera, Exit Algorithms: Yeah. Yeah, I'd agree. Yeah, no, I love that insight too. those are really interesting use cases. If you're not in the medical industry at all, you know, you know, probably didn't hear about. So yeah, fascinating. Well, Alex, I love this conversation and we're up on time here. last question I'll leave you with, and you touched on this pretty well already, but if you could leave listeners with one practical takeaway. For business owners wanting to prepare for a high value exit, what would that be?
ALEX FERNANDEZ: The best time to build exit value is when you have no intention of exiting. So build the business as if you're gonna sell it and continue growing it as if you're gonna sell it, even though in your mind you're not going to do an exit. If you do that, you will have an amazing opportunity, an amazing business that will grow. will provide a lot of wealth for yourself as the owner, as a capitalist in the in the organization, as the shareholder of the business. someday, whatever that is, maybe the oxy the exit will happen because everything's already in place.
Pete Vera, Exit Algorithms: Incredible advice. You give some advice today, Alex. Thank you for your time here. where's best place listeners, listeners can find you, learn more about you and your work?
ALEX FERNANDEZ: Well, thank you. Pete, a pleasure. LinkedIn, Alex Fernandes on LinkedIn. also all the all it social media, Instagram X, it's all the same, Alex Fernandez MBA, and YouTube, et cetera. So I I really appreciate being part of the show. love the opportunity to share with others and Pete, much success to you as well.
Pete Vera, Exit Algorithms: Yeah, thanks, Alex. Thanks for your ⁓ your dog also. It still seems still in the background there.
ALEX FERNANDEZ: Yeah, he's kinda hanging out here. Bocce. wants to be part of the show.
Pete Vera, Exit Algorithms: Awesome. All right. Have a great day, Alex. Thank you.
ALEX FERNANDEZ: Take care, likewise.
ALEX FERNANDEZ: Pete, thank you. Pleasure, my pleasure for you having me here. ⁓ you know, like we talked in past, been an interesting and love what you've been doing as well and what you're with the world, around ⁓ you know, basically growing your business and and creating value in order to create an exit. So, you know, my background, I you know, I personally I I started in the front desk. I ⁓ you know, I was going to school and I wasn't really thinking I was my parents are not doctors. I'm not a doctor or anything like that. I'm a business guy, so I went to business school and but I needed a part-time job. So in the nineties, I just got a job doing at the front desk in a in a doctor's office. And You know, over the years I just learned the the intricacies of of running and operating a a successful medical practice. whether it's revenue cycle management or managing your expenses and accounting, recruitment, company culture, and basically creating something where I you know, I always thought I always saw the physicians as you know, they're super smart people and they great at medicine, but they never d they don't teach business. They very few, I mean I've felt I've dealt with very smart executive physicians, but the majority are really good at what they do. They heal people, they get them back, you know, whether it's orthopedics, they get you back running or walking. if it's, you know, gastroenterology, they cure your cancers or they make you feel better because you might have ulcers or whatever. If you're an OB, you're delivering babies. You know, they they really good at what they do. But when it comes to growing their business, it's very similar to any other industry where it's kind of small. It's usually one doctor or two or three because they bring in some partners that augment the the relationship and the opportunity for revenue. And then they're always trying to figure out how to reduce costs. So they hire an office manager, and that person, in some cases, somebody maybe that grew up in the company, similar to what I did, different from me. I do have an MBA from University of Miami and and and I've you know run hundred million dollar businesses. But when you start at the beginning, it's it's just the basic platform of growing an organization, creating a culture. creating a business that can run without you looking for ancillary revenue streams or ancillary business opportunities that you can plug in or or bolt onto the business so that the business can continue growing and you can go on vacation for three weeks to Europe and nothing falls apart.
Pete Vera, Exit Algorithms: Yeah. ⁓ exactly. That's the the secret sauce. I I I think we'll probably get into that a little bit ⁓ more in detail later. but yeah, you were talking on the pre-show about your your background in PE backed companies. I do you mind sharing a bit about that, you know, your first experience being CEO and then all the that journey to to eventually exit?
ALEX FERNANDEZ: Yeah, yeah. Yeah, so I started with the the journey there, particularly with Gastro Health. Gastro Health was a group of several medical businesses or doctors that came together basically. three groups that knew each other, they say, hey, we have to like we merge and we form one bigger entity, we'll be able have leverage around cost, around revenue, around marketing, around branding, et cetera. We'll be able to put our monies together and through economies to scale, be able to invest in in our opportunity in our business to generate more wealth for us, the doctors, the shareholders. and then over the years, when I came on board, what we did is we just continue growing. particularly growing through a lot of mergers, small acquisitions, hiring more people, hiring more doctors, and just continue growing the business. And when it got to a a point of, you know, which I think, you know, for for private equity, there's that five to ten million dollar magic number that that they're looking for. Sometimes they do go in and and and buy businesses that are smaller than in the million two million range in in regards to earnings, but the really the sweet spot is above five. If five to ten is is great. And if you do 10 to 15, there's a lot of other opportunities if you're in the 15, 20, 30 million dollar eBIT business. But if you're in the smaller scale, the key is growing the business and adding and bolting on, like I mentioned before, some ancillary revenue streams that can augment the business outside of from what the in this case the what the physician does. so the the grew to about seven sixty of revenue, we're about sixty of revenue close to 10 at Vida back then. Back then the values were going around 10 times ⁓ multiples of of earnings. So it was an over $100 million deal. to to get that platform done and then that that business has exited again and that business close sold to close to a billion dollars in ⁓ the second time around second what they call the second bite at the Apple. so I think the key is more around a practice if if if a practice is a job that you own, or is it a platform that that runs without you, I think that's really the the big clip, you know, the big idea. A a practice is a job you own, a platform runs without you. so, you know, do you wanna buy something that, you know, some some people nowadays are talking about buying ⁓ businesses are AI resilient, you know, buy a laundromat, buy a, ⁓ you you know The guy that does A HVAC work, et cetera. But if you buy a business like that, then the the bigger question is, is the business gonna be able to run without you? Or you're the guy that you're an HVAC guy and then just get into that business. You're you're a a trainer and you buy a gym and you're just basically buying your a job. ⁓ so you have to figure out a way to scale the business up so that you can, you know, sit back and look at it from a capitalist perspective as an like you're also an investor, not just the day laborer that's ⁓ the wheel and making things happen.
Pete Vera, Exit Algorithms: Yeah. Yeah, definitely. Wow. and the deal specifics, do do you did you ⁓ any rolled over equity in that? in that initial ⁓ okay. you did get second battered apple when they exited again. Yeah. Did you do you recommend that that structure as a you know as a CEO of a company? Did you did you like that? you know, this how was it ⁓ how was that transaction?
ALEX FERNANDEZ: Yeah, yeah, yes. Yeah, yeah, yes. Yeah, of course. But I I I yeah, no sorry, f fin finish the the the question. I I I didn't mean to
Pete Vera, Exit Algorithms: No, yeah, yeah, I was just d any any feedback on how that transaction ⁓ for you and and did was the were happy with the the at the outcome of the the sale?
ALEX FERNANDEZ: Yes, for sure. Yes, I was happy with the with the exit. I will frame it differently. I think from an owner operator, and in this case, I was a partner operator is the way I would look at it, because there were multiple partners in the deal. but as an owner operator, whether you're a family business that's growing and then you figure out you might want to retire or I might want to ⁓ do something different because maybe my kids are not gonna take over or somebody in the business is not gonna take over or they might not have the capital to be able to buy the the the organization. I think the key is more around structuring ⁓ enterprise in a way that if you are gonna stay on board as a CEO for a period of time, you really with your lawyer and with counsel kind of figure out what the mechanics of that looks like. Whether you're Hey, I sold the business. I'm gonna give you 90 days and I'm out. Or I'm gonna sold the business, but I expect to be here for the next 10 years. And what do the mechanics look like that? Because I think know, I I've done it where I th I feel my sweet spot is getting into these smaller medical practices, putting them together, bolting them on, growing them to a certain level, doing an exit, you bolting them again, doing and in and doing that where I the people that when I left, the people that replaced my role are people that have run much bigger organizations that might not necessarily have the skill sets that I have to bolt it on, to make you know, to start from small. And I think that there's different stages in any business and my my sweet spot, it's the smaller businesses and growing them to a point that they can exit to an organization. Personally I've done it in healthcare, but I I I probably do this in any other industry as well. The the mechanics, the the KPIs, the the way that the business works is they're all the same. it's just, you know, growing a business that that that can generate and do more than what you personally are gonna put into it. I I always say that, you know, the the idea is, you know, you know, i every business or the same bus same EBITDA, different multiples, and the structure is why. You know, w why is why is is are you gonna get, even though you have let's say two million dollars worth of EBITDA, gonna get a six multiple where somebody else has two million dollars EBITDA and gets eight. People tend to focus more on, ⁓ well this guy got paid more than that. Well the question is why? Why did they get paid more? What did they do?
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: That they they leverage their organization. Maybe they have better margins. Maybe they can grow their business setup for growth. They don't have to bring in a CFO because they already brought you already have the team in place. the investment organization doesn't have to put as much into the the business after they acquire it in order to grow it and or are you gonna or are they acquiring you because you're all basically a a something that they're gonna add ⁓ on tuck into the enterprise that are. already exists. There might be a b larger private equity firm and I did I've done this as well. I did or thirty something transactions when I was looking at smaller medical practices that I wanted to acquire or that I acquired in order to bolt in or tuck into our enterprise business in order for the bigger business to be worth more.
Pete Vera, Exit Algorithms: Yeah. Yeah. What are some of those big ticket items would you say that, you know, that command a higher multiple, comparing two b businesses with the same EBITDA?
ALEX FERNANDEZ: Yeah, I I it starts out well, I would say in in healthcare or in medical practices, there's typically a lot of doctors. Especially when you get to larger numbers, there's that means that there's a lot of people involved in the in the in the business as owners or shareholders. ⁓ currently the business I'm with has providers, people that provide care. Some are surgeons, some are physical therapists, some are radiologists, anesthesiologists, et cetera. But there's a smaller group of people that are owners, but I still have two dozen owners in the business. So want or you know the owners, the shareholders are thinking, well, I think this is the right strategy or this is where we need to go or this is what need to do. And I think the key in in growing a business is making sure that everybody in the business, owners and non-owners, are sharing the same vision, that we're all in the same boat, that we're all rowing in the same direction, that we're all showing the same flag. you you wanna make sure I've I've owned, for example, real estate businesses as well. I'm I'm a real estate broker in Florida. And hard part is when, you know, ⁓ you have a real estate broker that's really good and he wants to like have his own brand and create his own thing, but he doesn't want to own the business and he doesn't want to be a broker. He doesn't want to go through the the complexities and the the the things that ha have to do that. You have to make sure everybody in your team ⁓ is your team. And they're all seeing the same vision, same growth. So I would start with with the the basic idea that the organization ha and everybody in it has to be going in the same direction, has to have the the same idea, whether that's growth, whether that's growth through sales, growth through acquisitions, integration, etc. And then the next part I would say that the bridge a significant amount of opportunity for a higher multiple is your team. Are The one person that does it all, CEO, C O O, CFO, C marketing, you're you're everybody. But on top of that, you don't even have anybody under you. Like the next level under you is the workers. There's no management team. there's no whatever. Granted, I mean, we know that with AI, it's interesting now. You have like hundred million dollar businesses, exits that are that are being acquired, and there's like two people in it because you have AI running it. So I think that's a leverage too. If you are able to utilize AI in a way that you can grow your business with a lot of with a with little overhead, I think that that's also important. But more importantly, it's I think it starts out with vision, and the whole organization going in in the same direction. And then finally the idea that have a team that you've built that is more of a platform than The opportunity to be a tuck in. So if you can build a platform and you have the right amount of EBITDA, you'll be able to get a much greater multiplier on your earnings.
Pete Vera, Exit Algorithms: Yeah. ⁓ that that's great advice. yeah, and I I think it's really useful for listeners to to hear the a buyer's perspective, you know, so they can shape their their business to be attractive to, you know, whatever buyer they want. when when does, you know, from a acquisition standpoint, when does it make more sense to grow via acquisition than ⁓ than organic growth?
ALEX FERNANDEZ: I think it a lot of it has to do with your current earnings and leverage that you can get from a an institution, whether it's banking or you know, leasing or or whatever institution, your SBA, wh whatever you're doing. Because if you're a single owner and you you have, I don't know, a lawnmower business. And you're the guy that cuts the lawn, it's gonna be very hard for you to go in and buy another lawnmower business. You might buy another route, which means you're gonna work more, but doesn't necessarily mean that you're gonna be able to create bigger wealth, you know, through an acquisition. but on the other hand, if you're the guy and you have 10 guys cutting grass and you've been growing that business and you have a certain amount of earnings or eBa, you know, leftover income, and you can use that to go to SBA or go to a bank or or say, hey, I'm gonna, you know, buy this small business, they're worth another million dollars. And, you know, I I'm gonna come up with, you know, 20, 30% of it cash and I need to borrow 70%. And you have people in your team, whether accountants, lawyers, people that that can back you up, consultants that can back you up and and help you frame the business model of why this is important. And why you should go ahead and and do the next the next step by by building buying the next business, then that probably makes sense. I mean it it ⁓ on the other hand, if the business ⁓ that same business it's stayed away, that might not necessarily be a d a good business, a good business idea. On the other hand, if it's contiguous to your market and if you are in one county and you maybe are going to another county or if you're one city and you're doing another city within the county, that probably even makes more sense because it's still within an an area that you can you can reach, you can manage, you can provide good customer service. if something goes wrong, you can go visit your client and and talk to them and find out why they're not happy and how you can make it better and so on. But if you're trying to grow the business in a particular market, And then you go to another market, that's great. You go to another market, that's great. But then the next leap is like, ⁓ I'm gonna go from Florida to Chicago. why? ⁓ what the hell is that all about? You know, why why buy another business that's literally thousand miles away that you have to get on a plane and and spend three hours? Now you're you're gonna dilute the business you're in unless it's a really great opportunity over there and you have a really strong team that can back you up. In other words, now you the business at a point that you can leave it for two, three months and to start and take over and bring your mission, vision and ideas to this other state, that might make sense. But I think if you're in a particular area and you and there's still a lot of growth in markets around you, why not just continue growing in the market that you're in? So I I I think it's two prong. First you have have the skill sets, number two money, and then number three, the opportunities that are nearby versus opportunities that are really far away.
Pete Vera, Exit Algorithms: Yeah. ⁓ yeah. All all that that makes sense. All that that all goes into it and timing is is a big element there too. you know, I I read a statistic recently that said over percent of deals fall through during due I I'm curious to know from your experience of a lot of deals, you ha what are some of the common causes of deals going sideways?
ALEX FERNANDEZ: Yeah. Yeah, I I would say that I I personally haven't had a lot of deals fall through due diligence. And I think a lot of it is because I do a lot of pre-du diligence before acquisition. And I think so I I I always look at it as like when you're gonna enter in a transaction like this, it's almost like you have to date a lot. And you get ⁓ And then you get married. I think a lot of organizations just get married. ⁓ so I th yeah, so I think that you know the key is when I when I started talking to a medical group that I'm looking to to bring on board, I'm looking for what are pain points? You know, is it that they just want money? If they just want money, it's probably the wrong the wrong deal.
Pete Vera, Exit Algorithms: Yeah. Throw the ring on.
ALEX FERNANDEZ: On the other hand, if they have pain around opportunities that I can bring They leverage success, something that's gonna, you know, in in our business in healthcare might be contractor rates. We we have we we get a a state rate that's ⁓ negotiated by an insurance company, let's say United. So if United pays you dollar for dollar, you know, well that's great. But if ⁓ pays me dollar fifty per dollar, well, I have a really good strong proposition that if I go in and bring you on board, even if there is a, you know, even if there's some earnings, there might be some idea of a increased revenue for the person selling. So there I've done deals where even though the doctors, for all intent and purposes, are selling and we're making earnings out of the business. they actually make more money. So it's like the the I would say the multiple wasn't times three or that. The multiple was infinity because I actually paid you and you're making more money than when you before after you sold. So th you know that there's really not a multiple of losses. There's a multiple of earnings that's positive, which a significant amount of opportunity. So it might be that. It might be that, you know, somebody's retiring in the group and the the lead doctor is going to retire and he's worried about he's the one that's been running it. The other three doctors in the group are not very savvy around business or marketing or, you know, billing, which is revenue cycle management, how we how we get paid by insurance companies. So therefore, they might need somebody to come in with professional management to take over the business to help them run the business moving forward. So if you say, I'm going to give you better rates, going to run your business, you can focus on providing medical care, you're still going to be a shareholder, you're going to make more money than you did before. It's a win-win for everybody. But if the idea is, hey, we're fantastic, we're a magnificent business, we don't have anything wrong with us. And we making $500,000 worth of earnings. don't know. What what am I gonna do? ⁓ you what? You know, and then you don't wanna change. There's nothing wrong with you. You just want me to pay you f you know, you make five hundred thousand dollars, you want me to pay you, let's say, five times earning, I'm gonna pay you two point five million dollars, and you go away. so the business you buy it and the business walks out the door with retirement. So and then to replace it, you have to find doctors. And in the healthcare business, much harder. to replace the talent than there is in ⁓ other industries where, you know, again, if you're HVAC business, you can hire more techs. If you're in the I don't know, you know, supply or accounting, I mean the the more professional the business is the harder it's to replace. I've had friends that have invested in in CPA and I'm like, you know, the C P A leaves, the business just walk out the door and you get, you know, you get holding
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: And it's not gonna be that easy to go ahead and replace ⁓ with another CPA. You can replace somebody that's that can do the work, but you can replace somebody that can manage the business or or bring business in, et cetera. So
Pete Vera, Exit Algorithms: Mm. Yeah. And that touches on a a theme you mentioned earlier too, building a the business to be able to run without the owner. do you think business owners should think about building a building that management layer you know, a a few years out at least before before considering a sale?
ALEX FERNANDEZ: Yeah, I think it's critical. particularly there's a lot of businesses. I grew up in a in a retail business. My parents had bridal stores. They have multiple stores, but it was my dad and my mom. My dad and my mom were the you know, typical mom and pop organization, but we have four or five stores. I mean they they had a significant footprint in a mark in a particular market area. but they never wanted to go ahead and and bring in other talent. They felt like, well, you know, I'll talk to my CPA about taxes, or talk to my lawyer about, you know, a transaction or a lease. But they didn't want to bring in any level. Funny enough, my youngest brother was the one that was really interested in the business. He liked photography and the bridal business was ⁓ included photography, et cetera. And And their exit, it was my brother. My brother's the one that ended up buying the the business and my my father passed away years ago and my mom is the one that stayed behind working with him and provided a great opportunity. So I think that there's if the business can ⁓ generate bring in talent, whether it's and I would say a couple years before, if you're thinking of exiting today, you pr probably should have thought about ha bringing people and bringing some talent years ago, you know, three, four, five years before. And at some point in time you have to bring in you have to build the infrastructure where if you can go away for a month on vacation and just routinely call and say, Hey, how are things going? And you look at the computer and you see either whether it's a CRM or you're looking at your your ERP system, you're looking at your computer or bank QuickBooks, you know, to put it ⁓ more more explicitly, you're looking at QuickBooks and sales are going through, then the business is doing well. And yeah, maybe it dipped a little bit because there are some things that you do personally as a business owner. But if the business is doing right relatively well or even succeeding while you're not there, that's the business I would like to buy.
Pete Vera, Exit Algorithms: Yeah, definitely. An asset that runs without you know, runs by itself, you're gonna get a lot lot higher multiple from that.
ALEX FERNANDEZ: Yes. Correct. Correct.
Pete Vera, Exit Algorithms: yeah, great, Alex. And I wanted to make sure we touch a bit about AI. I'd love to hear your perspective. how is it affecting your industries the most and ⁓ and are you using it personally?
ALEX FERNANDEZ: personally I'm still dabbling. I I will say this. I'm primarily, you know, using it to develop financial statistical ⁓ projections, know, things that would take my analyst to provide to me. they they you they still the analysts still run ⁓ all the reports and per and per present them to me. But now I can th those reports and generate, you know Probably I think it's more things that I already know, but it kinda puts them in a perspective. It's like, hey, ⁓ the you know, strength and weaknesses of the business right now, you know, where are the opportunities, where are the areas that I should focus on? So that's primarily w where I'm where I'm doing but I'm I'm being deliberate and disciplined about the AI. I'm not deploying it where you know what I can't measure or govern. I'm not using it to like let's say code new software. I'm not a coder. But I know people are doing that or or I hear co working, having basically an assistant that does a lot of work. But I I we are starting to dabble around the AI, Basically answering the phone. Instead of the prompt being press one for this, two for that, three for that, we have an AI agent that kind of talks you through. In particular, we're using it for two areas. capture, for example, in doctors' offices, it's hard to get through the phone. So half of the time you can't get through the phone. Well, I what if I could answer every single phone call? And if all you want to do is cancel, why can't I just go ahead and cancel the appointment? So I can have the AI cancel the appointment and have an open slot and then immediately text maybe people that are on a waiting list. us to come in sooner and say, hey, we have this open slot. Do you want it? And you know, first come, first serve. Whoever gets, you know, whoever says yes first gets the appointment and I get people in the door and I don't have any open slots in my schedule, which I think that's extreme extremely important to to a doctor's practice. we're also looking it in in regards to payment. So if you just want you got a bill Typically you're like, why do I hold forty bucks? I thought I I paid everything. And then the you ask the question and the AI could come back and say, the forty dollars was in addition to your copay because you have a deductible outside of your copay for $300 and you've met it to $120 and $40 is what's left over. And you're like, okay, would you like to pay the bill now? And they're like, Yes. And then it sends you a text and you put in your credit card payment information and say yes.
Pete Vera, Exit Algorithms: Mm.
ALEX FERNANDEZ: And the payment gets done and the whole loop gets closed. So I think that there's for sure opportunities where I'm not looking at it from a per perspective of reducing staff. I'm looking at it more from a perspective of expanding my my my staff or my capabilities from my team, given that ⁓ some point in time I don't have enough money to hire a hundred more people. I can only you know, so at some point in time i the the idea is how can I leverage the AI talkment and generate more profit or more revenue from what you already have without having to scale back. I do feel that there are some jobs and I see it already, there's some jobs that in the future are gonna change, no different than when, you know, I started this industry 30 years ago and I was doing paper claims. I literally you fill out the the claims that on paper and send them out to the insurance company in the mail. And then later on you started using a computer and filling out the information on the computer. And then it literally I remember dialogue mode and going whatever. And then basically sending out the information to to Medicare and the carriers and the and technology continues to evolve. So I think staffs will to evolve, people will have to evolve in your organization. And as CEO, I think it's my job to make sure that I'm giving them the tools, the education, the training to help them get there. so I I I feel like in the future there will be somebody that's a medical assistant that takes care of let's say prescription refills, might have a couple different agents that do prescription refills or a nurse that does that and and they kind of like manage that work with multiple people. so and then another will do else. I I think in healthcare it's gonna be very hard to replace AI, particularly because we have to touch people. Even when we were doing telemedicine during the 2020, 22 or during COVID, we were doing a lot of virtual visits. And think even that over time scale back because people wanna see, they wanna touch their doctor. They want the doctor wants to touch them. They're like if you're in in dermatology, we wanna check your skin. If you're in orthopedics, we your knee hurts. I need to touch your knee to see where it hurts. Your your gastroenterologist, you tell me, well, I have my belly hurts. Like they have to literally push on your stomach to make sure, you know, they they know where what hurts you, what ails you in order to figure out what the next thing is. I do he I do see and hear from our doctors that patients come in with like, my AAI told me that I need to do this. I'm like, or my recovery was that I'm like, well, I'm not sure that it's a hundred percent wrong, but this is what I think you should be doing. I am your doctor. so I I I do feel like in some areas it's gonna evolve much faster than others. but I think there's a lot of jobs, particularly in healthcare in a lot of industry that that require physical work, that it's that's not go away. I mean, I just don't I don't see the AI picking the watermelons off the But maybe with and robotics, maybe we'll do some of that. But I I think we're probably sometime away. Not not thirty or forty years away, but But not tomorrow either. Somewhere in the middle.
Pete Vera, Exit Algorithms: Yeah. Yeah, I'd agree. Yeah, no, I love that insight too. those are really interesting use cases. If you're not in the medical industry at all, you know, you know, probably didn't hear about. So yeah, fascinating. Well, Alex, I love this conversation and we're up on time here. last question I'll leave you with, and you touched on this pretty well already, but if you could leave listeners with one practical takeaway. For business owners wanting to prepare for a high value exit, what would that be?
ALEX FERNANDEZ: The best time to build exit value is when you have no intention of exiting. So build the business as if you're gonna sell it and continue growing it as if you're gonna sell it, even though in your mind you're not going to do an exit. If you do that, you will have an amazing opportunity, an amazing business that will grow. will provide a lot of wealth for yourself as the owner, as a capitalist in the in the organization, as the shareholder of the business. someday, whatever that is, maybe the oxy the exit will happen because everything's already in place.
Pete Vera, Exit Algorithms: Incredible advice. You give some advice today, Alex. Thank you for your time here. where's best place listeners, listeners can find you, learn more about you and your work?
ALEX FERNANDEZ: Well, thank you. Pete, a pleasure. LinkedIn, Alex Fernandes on LinkedIn. also all the all it social media, Instagram X, it's all the same, Alex Fernandez MBA, and YouTube, et cetera. So I I really appreciate being part of the show. love the opportunity to share with others and Pete, much success to you as well.
Pete Vera, Exit Algorithms: Yeah, thanks, Alex. Thanks for your ⁓ your dog also. It still seems still in the background there.
ALEX FERNANDEZ: Yeah, he's kinda hanging out here. Bocce. wants to be part of the show.
Pete Vera, Exit Algorithms: Awesome. All right. Have a great day, Alex. Thank you.
ALEX FERNANDEZ: Take care, likewise.
