Most dentists looking for a practice to buy would have passed on the one Dr. Michael found. It was 100% Medicaid. The building had not been updated since 1985. The dental chairs were cheap Chinese models, and one of them had actually caught fire. It was doing a million dollars a year in collections, but the net after Medicaid reimbursement rates told a different story. He bought it anyway, for $240,000 in Yakima, Washington, one of the poorest counties in the state.

Ten years later, he runs a 12-operatory practice with three doctors and seven hygienists, draws implant patients from 100 miles away, and was sitting across from Gary Bird and Dr. Blake at the Dental Success Summit when this episode was recorded.

What he built is not a story about finding the perfect market or having the perfect starting conditions. It is a story about understanding the market you are actually in, not the one you wish you had, and making decisions accordingly.

Why Dentists Overlook Rural Markets

The conventional wisdom is that you need to be in a growing suburb, close to a dense population, in a market with strong insurance penetration and high household income. That logic is not wrong, but it ignores a different kind of opportunity.

In Dr. Michael’s market, there is one dentist for every 3,000 to 5,000 patients. That ratio changes the entire equation. Yes, the area is blue-collar. Yes, average household income is lower. But when a dentist can serve a patient base that large with minimal direct competition, the growth ceiling is not the market. The ceiling is the capacity of the practice.

Rural markets also reward a specific kind of relationship. Dr. Michael has been mailing postcards with photos of his family for ten years. His patients have watched his children grow up. They bring those cards in when they come. In a small town, that kind of consistency builds something advertising alone cannot replicate. It builds trust, and trust is what gets patients to accept treatment and refer their neighbors.

The quality-of-life argument matters too. A 15-minute commute, no traffic, family nearby, and a view of Mount Adams and Mount Rainier from your drive to work is not a compromise. For dentists who are building a career and a life at the same time, that is worth more than the zip code.

The Medicaid-to-PPO Transition: What Actually Works

Dr. Michael’s practice was fully Medicaid when he bought it. He was extracting teeth for $33 reimbursement, doing five or six extractions per patient just to reach $300 in production for that appointment. It is unsustainable math, and he knew it.

But he could not simply turn it off.

The patients he had been seeing for four and five years were real people. The kids he had been treating since they were young were real kids. Cutting off Medicaid immediately would have eliminated the cash flow that kept the practice running long enough to replace it. So the transition was slow and deliberate: one insurance patient at a time, one color-coded schedule block at a time, until the mix gradually shifted.

Two practical realities came out of that process. First, the clinical speed he developed working at volume through Medicaid years now serves him in a completely different way. Extractions that once filled his schedule now take 35 seconds. That speed, built under the worst economic conditions, became a clinical edge once the patient base improved.

Second, the transition required him to accept that some longtime patients would be frustrated when Medicaid was eventually dropped. He held on to pediatric Medicaid patients for two years longer than was financially logical because he was not willing to turn away kids he had been seeing since they were toddlers. That is a personal decision every practice owner has to make on their own timeline. What matters is that the transition happens intentionally, not reactively, and not all at once.

The Marketing Reality for a Rural Practice

Rural markets have a ceiling that urban and suburban markets do not. There are only so many people within a reasonable drive radius. When you run a digital campaign in a small town, you can reach everyone in your market in a single month. Dr. Michael has had patients tell him they are tired of seeing his face on Facebook after a $1,000 spend. That is saturation, and it happens fast when the audience is small.

The solution is not to stop marketing. It is to think about marketing in multiple layers.

The first layer is local retention and referral. Postcards, consistent community presence, personal brand, and relationship-based word of mouth. These are slower and harder to measure, but they build the kind of loyalty that keeps families in your practice for decades.

The second layer is offer-driven acquisition. Dr. Michael runs new patient specials with a low barrier to entry. The conversion rate on a $99 cash special is around 33%, compared to roughly 85% for an insured patient. That gap matters, but so does this: nearly half of any patient population does not have dental insurance. If your practice is only built to serve insured patients, you are voluntarily excluding half of your potential market. A low-cost entry offer gives uninsured patients a path to your chair without a cost barrier that stops them before they even call.

The third layer is geographic expansion for high-value services. For implants, All-on-X, and full-arch cases, Dr. Michael draws patients from as far as 110 miles away. These are patients who have chosen to drive past urban options because the relationship, reputation, and availability in their rural area points toward his practice. For these services, the marketing investment justifies a broader reach because the case value supports it.

The principle across all three layers is the same: you cannot rely on a single channel. The dentists who get frustrated by a mailer campaign that did not immediately produce results are usually the ones who ran it once, with the wrong offer, and stopped before giving it enough time to work. The offer matters more than the channel. A campaign offering free whitening or a discounted cleaning delivers different results than one offering a genuine, high-value reason for a new patient to walk in.

Patient Financing Is Not Optional Anymore

Dr. Michael pre-qualifies every patient before they walk through the door using Cherry. No social security number required, just a name and date of birth. By the time the patient arrives, the practice already knows whether financing is available to them. Every patient is offered financing at every appointment, regardless of the dollar amount.

He made the point plainly: if you offer financing and a patient says no, that is fine. But if you never offer it, and a patient who would have said yes goes home to think about a $2,000 crown they cannot pay for upfront, that appointment cancels and the tooth gets worse. Patients often come back days or weeks later asking for the financing option that was mentioned in passing. If it was never mentioned, they do not come back.

The framing matters as much as the availability. Presenting a treatment plan as a total cost of $10,000 is a different conversation than presenting it as $150 a month. The clinical need is identical. The emotional response to those two numbers is not. Monthly payment framing removes the sticker shock that causes patients to delay or decline care that would genuinely improve their lives.

This is not a tactic for closing cases at the expense of patients. It is a way to ensure that cost is not the reason a patient does not get the care they need.

The Clinical Gap Most Dentists Are Not Talking About

When dentists say they are struggling with production, Dr. Michael asks a straightforward question: how many cases did you refer out this month?

If the answer is 15 molar endo referrals, that is $15,000 in production that walked out the door in a single month. That is $180,000 a year. And those are often same-day emergencies, patients in pain who need immediate treatment and are highly motivated to accept it.

The dentist who can do molar endo, place an implant, complete the bone graft, and do the extraction in the same visit, financing included through Cherry, can present that patient with a same-day comprehensive treatment plan. The dentist who cannot do those procedures can only offer a referral.

The willingness to invest in clinical skill development is not separate from practice growth strategy. It is the foundation of it. Marketing can fill a schedule with patients. Clinical capability determines how much of what those patients need can actually be treated inside the practice, and how much of the production opportunity leaves with a referral slip.

This does not mean doing procedures you are not ready for. It means being honest about which skill gaps are costing the practice real money and addressing them with intention.

Know Your Numbers. Track Two, Not Twenty.

Dr. Michael made this point on stage at the Dental Success Summit, and Gary reinforced it in the episode that dentists are analytical by nature. That tendency to track every metric becomes a liability when it leads to paralysis. If you are trying to move ten numbers at once, you are not moving any of them. And improving one metric often shifts another in the wrong direction.

The answer is to pick one or two numbers that are genuinely diagnostic of where your practice is heading, and go all in on those.

For Dr. Blake, the number is active patient count. Not new patients per month, not production per hour. Active patients. Because a large, growing active patient base means the hygiene department is full, the recall system is working, and the practice has a recurring revenue model that does not depend entirely on new patient acquisition every month.

For Dr. Michael, the current focus is new patient volume, because the practice has capacity to see more and the team to handle it. Getting those columns full is the constraint, so that is the number.

The right number depends on where your practice actually is. But the wrong approach is tracking everything and feeling busy without moving anything. Use AI tools to analyze your P&L, find the holes, and identify which single number, if moved, would have the largest downstream impact on the rest of the practice.

What This Means for the Dentist Who Feels Stuck Right Now

The dental landscape has shifted. Insurance reimbursements are declining. Labor costs are up. Patients are accepting fewer large treatment plans. Inflation has made the cost-of-living math harder for patients who were already working with thin margins.

Dr. Michael is operating in one of the toughest economic environments in the country, in terms of patient income levels, and he is scaling a 12-operatory practice. The principles that got him there are not complicated: know your market, build clinical skills so you can treat what walks in, remove every friction point between the patient and saying yes, offer financing to everyone, track the number that matters most, and stop waiting for conditions to get easier.

The practices that will grow over the next three years are not going to be the ones that waited for reimbursements to recover or for new patients to start searching on their own. They are going to be the ones that figured out what the market they are already in actually needs and built a practice around delivering it.

Frequently Asked Questions

Can you build a successful dental practice in a rural or small-town market? Yes, and in some ways a rural market offers structural advantages that are harder to find in saturated urban areas. Fewer competing dentists per patient means less price competition and greater patient loyalty. Practices in rural markets often have a one-to-three-thousand or one-to-five-thousand dentist-to-patient ratio, which creates significant room for growth if the practice is positioned and marketed correctly.

How do you transition a dental practice from Medicaid to PPO or fee-for-service? The most effective transitions happen gradually. Cutting off Medicaid immediately risks eliminating the cash flow needed to sustain the practice during the transition. A more sustainable approach is to prioritize insured and fee-for-service patients in scheduling, grow that segment of the patient base intentionally, and reduce Medicaid as a percentage over time rather than all at once.

Should a dental practice offer new patient specials with discounted pricing? When structured correctly, low-barrier entry offers serve patients who would otherwise delay or avoid care due to cost, particularly those without insurance. Conversion rates are lower than for insured patients, but these offers expand the addressable market and build a patient base that includes people who may eventually accept higher-value treatment. The key is having the right offer, not just a discount, and a follow-up system designed to get new patients back for a second visit.

How does patient financing affect dental practice production? Offering patient financing at every appointment, framed in terms of monthly payments rather than total treatment cost, removes the primary barrier to treatment acceptance for many patients. Practices that consistently present financing options tend to see higher treatment acceptance rates and fewer appointment cancellations from patients who want treatment but cannot pay the full amount upfront.

What clinical skills have the highest ROI for a dental practice owner? Molar endodontics and implant placement are consistently cited as the highest-return clinical skill investments for general dentists. These are same-day emergency services with high patient demand and significant case value. Every referral out represents production revenue that leaves the practice. Dentists who can perform these procedures in-house retain that production and are positioned to offer comprehensive same-day treatment plans that patients are more likely to accept.

What metrics should a dental practice owner focus on? The answer depends on the current stage of the practice, but the principle is consistent: track one or two numbers that are genuinely diagnostic of growth, not every available metric. Common high-leverage numbers include active patient count, new patients per month, production per hour, and hygiene reappointment rate. Trying to improve all metrics simultaneously tends to produce movement in none of them.

How does a dental practice compete when patients cannot afford treatment due to economic conditions? The most effective approaches include financing offered to every patient, monthly payment framing rather than total cost framing, low-barrier entry offers for new patients without insurance, and membership plans that keep existing patients engaged throughout the year. When the economic environment is tight, the practices that grow are the ones that make it easiest for patients to say yes to care they already know they need.

What These Conversations Are Actually About

Every episode of My Dental Playbook is built around the same question: what does it actually take to grow a dental practice, from the people who have done it?

Dr. Michael’s story is not a highlight reel. It is ten years of figuring out what works in a market most people would not have chosen, through a Medicaid transition that took longer than expected, with a team built one person at a time. The frameworks he uses now are the product of real decisions with real consequences.

If you are looking to shorten that learning curve, the My Dental Playbook Mastermind is where those conversations happen live, with people who are actively scaling their practices right now.

Join the Mastermind

Gary Bird and Dr. Blake run a monthly mastermind for dental practice owners at $299 a month with no long-term contract. It is a community of practice owners who are actively working through the same problems Dr. Michael described, sharing what is working, holding each other accountable, and making the kind of in-person connections that change how fast a practice can grow.

If you are ready to stop figuring it out alone, join us.

Listen to Episode 47 of My Dental Playbook here or wherever you get your podcasts.