PTO 75 | Private Practice Owner Coach

 

Reaching out for help from coaches helps us gain the needed insights for the development of our practice. In this episode, we are following up on the owner of Druid Hills Physical Therapy in Atlanta, Georgia, Dr. Avi Zinn, PT, DPT, OCS, about how he has developed his business. Although he has been successful in the development of his practice to this point, Avi reaches out because he recognizes that he needs to gain more business knowledge as the CEO of the business. He shares the importance of the stuff they did not teach in PT schools, such as tracking KPIs, leadership development, culture creation, and more. Learn how he is managing as a PT business owner and get a real-life look into what a business coach can do for you and your practice.

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Listen to the podcast here:

Reality Podcast Ep. 1 - Avi Zinn, PT Reaches Out For A Coach

This is the first episode that I have with an individual PT owner in which I'm going to follow along with him as he receives coaching and implement some of the coaching programs into his independent PT practice. Avi Zinn is a Physical Therapist out of Atlanta. He reached out to me to get some coaching and see if maybe we could work together to help him achieve his goals. Full disclosure, he didn't end up going with me as we talked a little bit about what I could provide and if that might fit for him. I actually offered him a couple of friends that he could call and talk to about getting coaching and consulting services with them and he decided to go with a friend of mine, which I'm excited about. Avi’s ready to grow and he needs to take the next step. I wanted to bring Avi in order to not only follow his path but also because Avi is pretty unique. He hasn't followed the typical entrepreneurial path. He didn't go through the burnout, the crash and burn stages that many of us may have gone through before. He did something different. I want to share his story with you.

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I've got Avi Zinn, Owner of Druid Hills PT in Atlanta. I'm excited to bring on Avi because he reached out to me in regards to getting some coaching and we've talked a number of times about his needs and how I could help him out, but things changed a little bit. He is looking for some coaching and consulting help and I want to follow his progress essentially and see what the coach or consultant has done for him to forward his clinic and to achieve his goals. This is the first introduction of that series of interviews because I imagine that down the road I'm going to do some follow-up interviews with Avi. I'm going to show you what it's like and what you can expect out of coaches and consultants and how they can help you as an owner. Let's get to know Avi a little bit and some of his influences and what got him to the point where he was reaching out. First off, thanks for coming on, Avi. I appreciate it.

Thanks a lot, Nathan. I’m happy to be here.

Tell us a little bit about you. Tell us a little bit about your professional path. How long have you been a physical therapist? How long you've been an owner? All that stuff so we can bring everybody up to speed on.

I went to PT school in New York. I finished in 2009. Shortly after finishing school, my wife and I moved to California and we went to the Bay Area. We were in Berkeley. I started my PT journey there. I’m looking for places to work, trying to see what was there. I found a cool PT practice based off their website. They’re more independent. The pictures of the clinic looked personal. They had a good vibe. I reached out to them and they hired me on, which was cool. Starting there was a good experience for me in a lot of ways, which ultimately led me opening up my own clinic.

Did you always have aspirations of having your own clinic?

No, not really at all. When I first started there, they had just done some coaching and consulting. They were in the process of transitioning their whole business model. I soon found out that when I started on, there was a huge turnover right before I came. I didn't realize that at first, but after being there for a few months, the remaining people that were still there were starting to talk about the old days or how things were different and not necessarily bad, but I think the change of the business structure led to other people just didn't agree with what they wanted. From following your show and all the people you've had on, it seems like that's a pretty common thing. You guys talk about your culture and your team. If you're changing your business structure and you're changing your team, then you’ve got to make sure that people are in line with that. I would assume if they're not, then they're going to leave or they're going to get told to leave. That led me to start my own clinic because it was an independent clinic. It wasn't a chain and it was two owners and they had a few locations at the time. I started seeing what it was like from the owner's side of things because they were at the clinic all the time.

You have to take risks in order to have something you desire to create. Click To Tweet

Whereas later on when I started working for chains or hospital systems, you don't see the owners at those clinics. You just see clinic directors or whatever. Being there, I saw that the community and the PT practice had a great reputation. People knew about it but at the same time, the employees, the staff, the PTs weren't saying the same things that the people in the community were saying about the PT practice. It was interesting to see how there could be a different perception that the patients are loving it, but the PTs aren't. That probably happened because of the change in the business structure and however that played out. I started realizing that there could be different ways of going about this business. Clearly, we're providing good service because people were talking about it and people knew about it but the staff wasn't happy. That was interesting to see. That's what really started me thinking about like, "Maybe I could do this." Everyone thinks, "I could do this." I thought, "If I am going to do this, maybe I'd make it so people are happy at their job."

There are a couple of different reasons why people open up their own PT clinics. Either they have an entrepreneurial spirit and they want to own the job and that's something that they have a burning desire to do. I'm sure there are many other reasons, but the two that come to mind are the second one being, "Maybe I can do this better or maybe I can create something that I can fill a need or I can create some value that I don't see in my current position. I can treat the way I want to and expand on that.” There are a number of different reasons in your situation, in particular, you're thinking, "The owners are doing great. They've got a great connection with the community, but the internal structure and culture could be improved. Maybe I could do that myself and create my own thing." Is that about right?

Yes, that's right, Nathan. You have to remember, I was in the Bay Area, that's a hotbed for startups and entrepreneurs. I do think that was a part of it. I remember a good friend at one point. I was talking about a startup and entrepreneurs. He even said something to me that I could be an entrepreneur if I started my own PT clinic. At that time, I didn't know what that meant to be an entrepreneur. I didn't realize that starting a PT clinic would be the same thing. Getting that entrepreneur bug, that's what I'm sure we'll end up talking about pretty soon in The E-Myth what Michael Gerber talks about. I think doing it better though and realizing that maybe I can do this in a way that would provide that service and also have the people that work there happy as well. What I was seeing at that clinic that combined with getting that entrepreneur bug, those two started the process of me thinking about at one point starting my own clinic.

You eventually went to Atlanta and decided to do that?

My wife is from Georgia. She grew up in Savannah and I'm from St. Louis. We were in California and we didn't know totally, but we started thinking that we would want to be closer to family. Atlanta seemed like a pretty good city. My wife did an internship in Atlanta and that was when I stopped that job. We went to for the summer to Atlanta to do the internship, but also see if Atlanta would be a city we'd want to move to. We liked it and when we went back to the Bay Area, we knew we were going to move there. I knew I wanted to open up my own thing or start my own clinic, but also knew we were going to move at some point. I never really wanted to do it in California. At that point, I started doing other jobs and experiencing different types of PT. I did work comp for two years. I started doing home health, which was interesting. I did that for a bunch of years.

Eventually, we did move to Atlanta and started doing home health when we got here to learn the city also. It was a good opportunity that I learned the city, but I was driving around for home health. I was trying to get a sense of where I would want to start a practice. It all happened at a time where I was ready to do it. This location opened up right in my neighborhood. Literally, a four-minute walk from my house. It's on the main street. It's across the street from this big shopping center on this road where they say 50,000 people drive by every day. It was perfect. Everything worked out. That's when I started to get things going because we found this place and I had been thinking about this all these years. It was time when this place opened up.

How long ago was that?

That was the end of 2017.

During this time, had you been reading any books about business ownership or accessing any resources?

When I was doing home health, I was driving all the time and I stumbled upon Paul Gough's podcast. That was really the first one that I started listening to. That was talking about owning a business and how to run it. I don't know if this is exactly what he said, but this stuck. He said, "You don't have to have the best PTs, you just have to have good PTs. You can hire the good PTs and you have to be the one who's working on the business.” The truth is I could be combining that with some of the other, like Michael Gerber, your show, but I believe he did say that stuff and it started making me think about how I was going to set up a practice and what that meant.

The cool thing is that it set up a mindset for you, knowing where you are. You don't have to be the best physical therapist. Soft skills are more important than hard skills. You already had an idea that you were going to bring on some other physical therapists anyways. It wasn't going to be the obvious in a physical therapy clinic and a one-man show. You had aspirations for more right off the bat. You've opened up your clinic and how did you start working in it? How did you start developing it, so that it wasn't obvious in physical therapy clinic? 

PTO 75 | Private Practice Owner Coach
The E-Myth Revisited: Why Most Small Businesses Don't Work and What to Do About It

When I was trying to figure out what to call it, I was really against calling it my last name, Zinn. A little back story. My father-in-law has his professional experience. He opens a lot of businesses. He was able to guide me through a lot of this in the beginning. Helped me set up the LLC. When I was looking at this place to rent and lease it out, he guided me through with creating a pro forma and talking to the landlords about having my financials in order, even though we didn't have the financials in order. Getting that set up and he was set on calling it Zinn PT. He wanted me to do that and I was like, "I don't want to call it Zinn PT. I don't want it to be about me." Maybe because of listening to the podcast and knowing Paul Gough’s podcasts, knowing that I wanted to bring people on and I didn't want it to be about me because maybe had a little foresight knowing that I would have to do the business stuff at some point and not always having people wanting to go to Zinn but to the PT practice.

What did you start doing initially to make it so that it was not Zinn? You ended up developing Druid Hills Physical Therapy, you were the initial physical therapist. How did you start the progress? This is an important part of the introduction of you. You did things a little bit differently and I'll highlight that as we go through the story.

First of all, I was still doing home health, which was a huge help because home health is super flexible and I was able to bring in some income while setting up the practice as a group. There was no other way to do it. I took out a loan. I could've taken out a loan three times the size and lived off of that for a while. That would have been a little overwhelming. Setting it up, I started getting things in order. I don't know if it was from the podcasts or not. I wanted to experience every part of the business at first to know what it was like so that I could start putting people in those places. When I started, I did everything. I was a PT but I was also running back and forth to the front desk to answer phones and schedule. Instead of a front desk person, I had an answering service, which was helpful and they would email and text anytime someone called. I had a doorbell. That was my front desk person. If someone came into the office, I knew someone was there and I could run back and forth to the front to greet them. I started getting things in place. Aside from the business things, I had to start getting patients.

I tried doing all that I thought would have been the normal way to do it, which was called doctors but that didn't work. It started with that. I was lucky that a third-party work comp insurance called me and they were like, "We want to give you a contract and send some people to you.” I was like, "I need people to send patients," which was also cool because work comp authorizes a certain amount of visits, they pay the rate, whatever it's going to be. You don't have to fight with the insurances. They're not going to like deny certain code, which was a great way to start. Because I got those patients, I knew those visitors were coming in and I knew they were going to pay whatever they paid. That was also a little bit of a hard part, to begin with, was the money part. How you charge people. All of it was hard. I didn't know how to do anything.

How long did you go like that before you took on your first hire and eventually before you got your next physical therapist?

I started at the end of 2017. We had our third kid in March of 2018. It was a great idea to start a business and have a kid the same year. Right after that is when I hired on the first PT. The business was growing slowly. Knowing that we were going to do this, I started looking back at the schedule and tracking what was happening. The schedule was pretty light. Looking back, I don't know how I was confident enough to even hire someone on.

That's the question I have for you. How many visits were you at per week before you hired that physical therapist because you went against the grain?

I don't know. At that point, I was doing three days a week at the office and still doing two days a week home health.

You brought on your PT at that point. This is why I wanted to bring you on is that you hired a physical therapist, what most people would consider is too soon. Based on my training experience and if you were to ask me, "When do I bring on my next physical therapist?" I'm going to tell you, you bring on the next physical therapist when you're meeting at least 90% of your slots that are scheduled out in a given week on average. That's the time when you know, I'm working hard or my other PTs are working hard. It's time to bring on someone else where these people are going to get overwhelmed. Maybe you even have a waitlist, but you went against the grain and you don't necessarily know why. You brought on a physical therapist because this is the thing, the typical entrepreneur story is we don't do anything until we get overwhelmed. Sometimes there's a crash and burn element to it. If you read to some of my previous shows and the successful entrepreneurs but you didn't get to that point, so you brought on the next physical therapist. You must've had some faith that things were going to go in the proper direction or maybe you had some real intent out there in the universe that things were going to grow?

It was a little bit of both, Nathan. I was thinking about starting a business, in general, is a huge risk and I've maybe realized that you have to take risks in order to have a business. That was the same move. I saw the trajectory and patients, it was growing slow but it was steady growth. It looked like things were going in that direction. It was time to hire someone on and keep it going.

During this time, were there some resources that you fell back on that might have stoke that faith or inspired you to bring on someone else so that it wasn't on you? Did you also maybe see that there were some aspects of the business that you needed to work on so the PT would take the treatment side of things off of you so you can focus on those things? Was there a combination of some of those?

Because of how busy things got, I realized that I had to do more of the business stuff. That was what it was. It was the beginning of 2019 or it must have been earlier when I started following your show. I remember in January of 2019 is when I started reading The E-Myth. I don't remember exactly when I found your show or how that happened exactly. Even before that, I realized that I had to be able to step away to do from treating, there were only so many hours in the day. I didn't want to be working all day long and then going home and working all night long. I realize that the only way to do it was to step back a little bit. It wasn't a lot, but it was by hiring another PT that I was able to step away and do a little bit more of the business side of things.

You have to take risks in order to have a business. Click To Tweet

The common fear when someone makes that first step is to bring on another PT. The biggest fear is, how am I going to justify that salary? I'm going to be paying somebody $70,000, $80,000. What if they don't work out and they don't produce? Somehow you overcame that fear. How did you do that?

After that first job in California and when we came to Atlanta, I did a traveling PT job. When we went back to California, I started doing PRN. When I learned about what PRN meant, that is ultimately when I hired my first PT, I didn't hire her on full-time. I hired her on PRN and it just happened that I found someone who wanted to do it. She was in a different job and she wanted to switch it up a little bit. She started doing two days a week with me. That is why I was able to not be so overwhelmed because essentially instead of making it five days a week for me, since I was only doing three days a week in the office, I made it a five-day PT but split between two people. I was able to have the patients coming in on all day, every day and then still have two days a week where I wasn't treating and doing some of the business stuff.

You were still running the front desk and taking all the calls and some of that stuff?

I was still doing that stuff and the billing, the front desk. Shortly after that, I got someone two days a week at the front desk. Gradually we started getting more patients, so that part-time PT ultimately wanted to switch all for hours over to this place. It worked out well because I didn't need to look for another person. She was already there. We were organically growing and filling those hours on the schedule without having to hire on a new PT and then have to be scared that you're not filling up their schedule for three months because we did it gradually anyways when she first started by two days and then added on more days.

She started taking on more hours. You started treating less it sounds like and you're working on the business during this time.

I don't think I really started treating less because for the most part, I was still treating the same amount, but it had blocked off certain times from the beginning to do billing, networking, calling people and driving around.

That's a huge part right there and I don't want to overlook that. You blocked off time on your schedule. As I'm talking to PT owners that are treating full-time, that's probably one of the biggest hurdles is to get them to commit to blocking off chunks of time, whether it's four days or 4, 5-hour blocks to work on the business. That is to look over your financials. That is to put together a pro forma like you're talking about. Consider what the future might look like. Do some networking. Even start developing some policy and procedures and hiring the right people to fill the spots that you either have open or are going to have open in the very near future. What you started doing maybe someone told you to or maybe you inherently knew you needed to do was to keep that time sacred for admin work.

Around the beginning of 2019 is when I read The E-Myth. That was transformative. I've heard people say it on your show a million times, working on the business and not working in the business. I think he came up with that. It made so much sense and you can't do it any other way. There's only so much growth you can have if you're working in the business. When I read the part about what a lot of people do is they create a job for themselves. That part was like, “I’m not trying to create a job. I'm sure I didn't try to create a business." I did somehow realized that I needed to keep that time separate to work on the business. Once I read that, it was when I started realizing I need to do more of this and if I want to grow, I need to not just hire more people. It would actually start taking more time to work on the business because once you start getting busier with more and more things going on, you need to have more time to figure out all the things that you had mentioned, which I still have not done yet.

We have to give it proper credit. The book that we're alluding to and referencing is The E- Myth Revisited by Michael Gerber. He does layout a lot of this stuff. When we say you working on the business, what are some of those things that you're doing? I have even some owners say, "If I'm not treating and I'm not catching up on my notes and I'm not paying bills, what am I doing?" What do you do in those admin times?

First of all, I still do the billing. That's part of it.

That's going to change soon. What are you going to do when the billings off your plate?

PTO 75 | Private Practice Owner Coach
Private Practice Owner Coach: The only way to implement your systems is if you take time away from treating and work on the business.

 

We'll find out soon. You did mention about policies and procedures. That's what I started doing was creating systems, which is what The E-Myth is all about. I created an organizational chart, which is another thing that they talk about in the book. Even though every single job in the organizational chart was me, I still was breaking up what created the business, all the different parts and all the different jobs that make up the business. I started writing out what happens under those positions, what one does for that job. Basically, I use Google Drive and Google Docs and I have a nice organized folders system of docs for every one of those job positions. Every time something happened that day that I had to troubleshoot or figure it out, I would put it in that doc and then I would try to create a system to make sure it didn't happen again or t try to delegate some tasks to the front desk person or the PT so that they can do it so that we wouldn't have to keep on going through the same mistake every time. We would know what to do every time. 

You wouldn't have to learn the same lesson twice.

Yes, we don't have to learn the same lesson twice. Also, we wouldn't have to be where someone had to knock on my door and asked me what to do for it.

This is why I love having you on. You're at a place in your ownership that I would say a majority of PT owners are not. I'm including the guys that have been out there for 10 to 20 years. They haven't taken the time to write up their policies and procedures. I can say I was in that boat 10, 12 years after opening up my first clinic. Didn't take the time to write down policy and procedures. I didn't have an organizational chart. It doesn't matter if you are in each position. At least know what the structure of your company is and what it should be and what it will look like when other people start filling those positions is huge. That comes as naturally to some people more so than others, but you're organized enough with your Google Docs to have everything written up underneath each job with a job description, the responsibilities and the tasks that are given to each position. That's huge and that is the reason why you are where you are is because you've done some of those things. How many therapists do you have?

We have three therapists besides me. They're all about 30 hours or so. Part-time but full schedules. One is actually reducing hours the same original one who wanted to take on more but also step out of her first position and try something different. She's going to try something different and reduce her hours, which is fine. Everyone wants to do different things. There's nothing wrong with it. We're about to hire another person and she's going to be my first full-time. We'll have one full-time, two pretty full-times, one part-time and then me.

Being less than a few years into your ownership. That would be unfathomable for some people. I'm talking to some owners who are one-man shows and they're overwhelmed and they're three years into it and they don't see a way out because they're treating 50 hours a week and not working on their business. Whereas you've set yourself up such that you have multiple providers and you're already experiencing some freedom that most PT owners don't have.

Nathan, you probably would agree with this, but for the people that are working crazy hours, I made sure I did this in the beginning, I worked at the office. I did some stuff at night, but for the most part, I was in the office 9:00 to 5:00, and that was it. I made it a point to stop at the end of the day. Of course, you do some stuff at night, you answer emails or you work on the website.

You had some intention behind putting an end to the day.

I think that's what it is. That has allowed me to keep going. It prevented me from burning out and I didn't get so overwhelmed because I was like, “This is the end of the day. We're going to stop, we'll pick it up the next day.” If I work an extra five hours, it's not going to be any different. You need to put a brake on it every once in a while.

There's some power to that. Number one, the time that you do have is limited. There's going to be an urgency to get things done. If you don't have that end stop, you're like, "I can work until 7:00 and I'll take my time getting things done.” Inevitably there’s something called Parkinson's Law that, "The amount of things to do will end up taking up the time that has allotted to do them." If you're available to work until 7:00, you'll have plenty of tasks to keep you busy. If you put that hard stop at 5:00, you've done two things. Number one, you've set a deadline, but also, you were concentrating your efforts on doing the admin work. You can get more done for the benefit of your company by focusing that time on your business than trying to get tasks done. Instead of trying to get payroll down or pay bills. I'm sure you were focusing on what some people call the MIT, the Most Important Thing of the day and that is developed policy and procedures. Get my organizational structure in place. You're doing the billing, but that's a separate chunk of time. The fact that you spent that time on the policy and procedures and the organization of the structure of the company means you've developed solid integrity around that and you've accelerated your growth as an owner and as a business to the point where you are.

There's only so much you know how to do. You need to reach out and ask people for help. Click To Tweet

To be clear, I still have a lot more work to do on the policy procedures and all that stuff. That's ultimately what we're getting at with coaching and consulting. In March of 2019, I hired on the second PT and then that's when I drastically reduced treating time down to twenty hours a week of treating.

Was that a scary transition or something that you're, "I need to do this?"

It wasn't scary at all. It was, "I need to do this." Partially because at that point I had read enough of your blogs and also had probably read to The E-Myth again for the second time or maybe even third time that I realized that it doesn't even matter if it's scary. That's what you have to do. There's no other way around it.

You recognize the need of the company was to go in that direction, right?

Yes and it was my business. If I'm treating, who else is going to work on the business? I have to be working on the business. There's no other way. 

You talked to me about doing some coaching and consulting. What led you to that point?

Where I've gotten myself have been a lot of working on the systems and policies, but at the same time, there's only so much I know. As the business grows and when we're getting more patients in one of the main things that I've noticed is there are cancellations and why are we having 30 new patients in a month. We had eighteen new patients in one week and that was awesome. That was the most we had. The following week the schedule was half empty and it was like, "How is that happening?" I started running analytics, WebPT. I called them up asking, "How do I find out how many times each patient is coming in?" I’m trying to see what their plan of care and how many visits per week? I find that a lot of patients are only coming once a week or they schedule two visits and then they're gone and no one was tracking that. I run this lost patient report from WebPT and then all of a sudden, I look and there are 50 to 100 people on this report of people that came in and we never got them back on the schedule. That was a huge thing.

You recognize that you need to start monitoring your metrics and if you haven't taken the time to do that, then the metrics will control you and sink you.

On the analytics and WebPT, they have their main KPIs. There are six KPIs on there and that was cool. I realized I don't know. I feel like I've done a lot to get myself here, but there are people who know a lot more to take those numbers to who've already gone through this, who can tell you how to use those KPIs, those metrics and what to do with them. How to affect them and also, one of the biggest things through all this realizing that I am not just the owner, but a CEO of the company. I need to learn how to do that. I need to know how to manage my employees, train them and set up different structures and have certain people responsible for different parts of the business. I realized that there's only so much I know how to do. That's when I was time to reach out and ask people to help me along that.

You realize that you are the final word. People are going to come to you because you need to have the answers for the company. I don't think a lot of physical therapy owners who are relatively new don't put on that hat per se. They think that the ownership somehow is not as separate from them. They know that they're the owner, but they don't act like the owner and that they should be monitoring all the metrics and the financials. They should have some idea of what to do when a statistic goes bad and how to look and investigate issues in the clinic. It sounds like you had that realization that you need to take on that hat.

Nathan, that part is hard. I went to PT school, I learned how to become a PT. I didn't go to business school. I don't even know if you learn how to do that in business school either. I don't know how to run a company. 

We're all in the same boat.

To answer your question, that's what it was. I realized that I needed to be the CEO essentially and I needed to learn what that means and how to do it.

You reached out to me and we had a conversation. I actually gave Avi some recommendations of other coaches to also consider outside of me and he has decided on another consulting company and I'm excited because he's going to do amazingly well. You can see that he's already set up the foundation. I want to follow you along this journey. How will you know if you've been successful with a coach or consultant? How will you know that they've met your goals? Is there a statistic that you want to see? Maybe gross revenues and net profits or is it more freedom for you? Is it growth?

PTO 75 | Private Practice Owner Coach
Private Practice Owner Coach: If you're changing your business structure and you're changing your team, then you got to make sure that people are in line with that.

 

I'm starting to understand financials and understanding gross revenue. I'm at the point where I can look at a P&L and understand it and gross revenue, of course. Let's get that up.

You need a return on your investment to the coach. You expect a multiple of your investment on the coach.

Having the patient drop-off, go away or at least get better. Maximize the utilization, which is something you were saying. If there's so many hours that the PT is treating, they should be treating patients that whole time or at least let's say 85% of it and figuring out how we can make sure that happens. Training the front desk also is the best way to take part in the patient's experience. Also, making sure that they're following through with their plan of care when the PT comes and brings them up to schedule. Making sure that they schedule it and making sure that they understand what it means and the cancellations are detrimental not to their progress but to the whole business. Probably a million other things at the front desk can do but hopefully, they'll help me out with all of that.

Are there some particular goals that you have then over the course of the next year or two? I'm sure the coaches will help you along with this, but what are some of your goals that you have?

As far as freedom goes, I don't need to be not in the office 200 days a year, which is great. Maybe one day. I like being in the office. I like working, but I don't want to work all day, every day. First, producing the treatment hours, that was key. I've done that myself, which is talking to you and talking to other coaches. That's what ultimately is going to set me up for success quickly with these coaches is because I've already done what a lot of people have to do initially once they start with the coaches is to back out of the treating.

You're a step ahead already.

That ultimately is going to allow me to focus on some of the goals a lot quicker. In 2020 who knows? Maybe this will happen in two months. If we have twelve hours of the day in the office, 7:00 to 7:00 and we have five PTs, I want to be able to fill up that schedule, which is ultimately going to bring in more revenue.

You're going to have to expand.

Yes, hopefully. These could be long-term goals. I remember early on Paul Gough that he’s talking about how he owns some of his own real estate and some of the practices. That could be a cool goal. I don't know so much about that on the numbers side. I imagine at some point it's beneficial, but maybe it's not always. That could be five years from now. I want to grow this space location that I have to maximize it. If I have to work twenty hours a week still treating patients, that's fine. I like treating, but I also recognize that I have to do other things. If I need to not and I can get someone else to do it, great. Maybe later on, in a few years, I can start treating again. Wherever the business needs, that's what I'm going to do. 

That your decision matrix has to be exactly that. Whatever the business needs. If you're not wanting to set aside time to work on the business and want to treat full-time, then go work for somebody and work full-time. Don't spend the stress and energy to own the business on top of it. If you're going to commit to owning a business, you need to put the business first. That comes first. What a lot of PT owners don't recognize is the clinic needs them to treat less, needs them out of treatment because it's a distraction to treat patients as an owner. You need to set aside times to work on the business and eventually what happens is they work themselves out of treatment because the needs of the business become greater because they were expanding and growing. I'm excited for you and what you're looking. From my perspective, looking at where you're at, you're looking to gain more knowledge so you can confidently and securely wear that CEO hat and become more efficient. You're recognizing that there is a lack of efficiency maybe in your company and you don't necessarily know how to affect it.

That's what I think when I pulled up that last patient report that one time and I realized, that's why our schedule is not full, even though we're getting all these new patients. We need to figure out how to make sure that doesn't happen. 

Work on the business and not work in the business. Click To Tweet

That's a dagger to the heart when you find stuff like that.

That was hard. 

It goes through a couple of things. That is a whole few pages, maybe one or two pages full of lost revenue. More than that, if you're looking at from a higher level, these are patients that didn't get the full complement of care. These are the types of patients that go back and say, "Physical therapy didn't work for me. I've been to Druid Hills Physical Therapy and it didn't help." You don't want that. That can happen unless you're focused on getting them to complete their plan of care. I said this in an interview that I did. I found out about it a couple of years ago when I interviewed Heidi Jannenga of WebPT, and they did their annual survey that most small businesses lose on average $150,000 a year because patients like those on that lost patient report don't complete their full plans of care. That's a detriment to you as a business owner. It's a detriment to them as patients because they're not getting better and the chance of recidivism or the chance that they didn't even get better is significantly higher.

It is a detriment to the profession as well.

We'd become a commodity. They say, “Physical therapy didn't work for me.” They don't say, "I'm going to try a different physical therapist." Like anybody would maybe with a dentist, they say, "Physical therapy didn't work, so I'm going to try something else." It's unfortunate. I'm excited for you and I want to follow along with you and see what you learn along the way and so we can share with the audience essentially the benefits of coaching. I wanted to share your story number one, because it's amazing that you haven't gone through the typical cycle of an entrepreneur that's even spelled out in The E-Myth Revisited. It's not in the physical therapy space, but I think she was a baker of pies and she had that burn out and she's like, "I can't do this anymore. I'm not seeing my family and I hate my job." You never experienced that because you looked ahead and started planning and started acting forward in faith that things were going to continue to grow and it's worked out well for you. You're going to continue to grow that you develop that foundation.

I want to say one funny thing that happened. We're in the process of moving houses. We're going through a bunch of things and I find a box of all my notes from PT school and I open up a folder from my business admin class, the one day that we spent on and pull out the handouts. There was right on the top was The E-Myth Revisited. I don't remember the professor ever talking about that back in the day. If anything, they were doing a good job teaching about business because they talked about The E-Myth. I'm sure there are other ways to look at it, but following that way of setting up systems and organizing the business and working on the business. That is what has allowed me to get to where I am.

What's different about you Avi compared to a lot of entrepreneurs, whether it's physical therapy owners or not, you've had it on the one book and I'm sure you've read other books, but this one's been influential for you. There are people out there that have read the book and I've read hundreds of others and aren't in the position where you are. The differences that you've actually taken action on what you learned. I read The E-Myth Revisited 6, 7, 8 years ago, but I didn't implement it to the level that you did it either. I would submit that people who are reading the business books, if they read The E-Myth Revisited, don't read it as a nice, good story, but to actually implement what he recommends. 

The only way to implement it is if you take time away from treating and work on the business.

You've actually put those principles into practice and that's what I separated you from somebody who is simply read the book. I'm excited to see your growth here as you get some greater insight and knowledge on how to improve your stats and become more efficient. We'll follow up with you and do another interview and see what you've learned and what's been influential for you. Maybe there are some pitfalls, maybe there are some things that happened along the way, who knows? You might experience for yourself what your initial outpatient company did in San Francisco. Maybe not everybody's aligned. That or everything is going to go in a great direction because you have your ducks in a row already. I'm excited to see what happens. Is there anything else that you want to share, Avi?

For anyone, if they are reading for the first time, reading your blog has been helpful also. I talked a lot about The E-Myth, especially because I've set aside some time to work on things. I'll read your blog whatever interview person you have on and then try to implement those things that day or that week. It's been also helpful to know other people's stories.

That makes me feel good. Not only a resource but an inspiration to you. Thank you for that. We will stay in touch and we'll come back around to the story that is Avi’s in Druid Hills PT.

I'm looking forward to it. 

Thanks.

Take care.

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About Avi Zinn

PTO 75 | Private Practice Owner CoachDr. Avi Zinn, PT, DPT, OCS is the owner of Druid Hills Physical Therapy in Atlanta, Georgia. He opened his practice at the end of 2017 and has slowly built it up—transitioning from a staff of one (himself) to a team of administrative staff and treating therapists. He continues to grow the practice gradually. Avi’s main mission for Druid Hills PT is to provide high-quality, personalized care to each and every one of his patients.

Avi has his doctorate in physical therapy from Touro College, and is a Certified Orthopedic Clinical Specialist. He lives with his wife and three children in Atlanta.

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PTO 74 | Internal Marketing Programs

 

Although Mike Bills, PT had plenty of managerial experience for a large hospital network, it did not prepare him for owning his own PT clinic. He quickly learned that owning and managing are two different ball games. Mike reached out and got some consulting support five plus years ago, stepped out of treating full-time, and has networked with other PT owners for the past five years. Now, his one-person clinic has turned to a 6,000-sf facility with thirteen providers, and they're continuing to grow in spite of the POPTs and hospital networks that have sprung up around them. What are they doing differently to thrive and survive? Today, Mike shares the formula to ownership success as well as their successful actions of obtaining new patients through their internal referral programs and social media/internet efforts.

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Listen to the podcast here:

Successful Internal Marketing Programs With Mike Bills, PT

I've got a friend of mine. I've known Mike Bills for a few years. We're both clients at Measurable Solutions. He's the President of Measurable Solutions for those of you that have been through any of their programs. Knowing Mike and the successes that he's had at his clinic, I had the opportunity to have a phone conversation with him. He shared with me how much they're growing and how well they're doing. I thought, “I need to bring him on because there's one aspect in particular during our conversation that stood out.” One of his most successful marketing actions is a robust internal marketing program to the point where a great percentage of their patients come from internal referrals from current physical therapy patients. They're not dipping their foot in the water here. They've been doing this for a number of years.

It flabbergasted me when I was doing the interviews. They do 30 minutes of drilling, training, and roleplaying with all of their 30 to 40 team members every week on how to get referrals from current physical therapy patients, not just providers. The entire team is responsible for this to the point where it's affecting their referral sources significantly in terms of internal referrals. Another example is that they've focused on internet and social media referrals. That's where they get the majority of their patients at this point. We go through that. He shares the powers and the numbers. They simply get a minor percentage of their patients from physician referrals. I want to share that with you because it's powerful what you can do with internal referral programs and the usage of social media and online marketing to the extent that I have seen from other physicians or physical therapy owners during the course of my show. I'm excited to share this insight with you. Let's get to the episode.

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I have Mike Bills, CEO and owner of Loudoun Sports Therapy from Sterling, Virginia. He is also the President of Measurable Solutions. For those of you that might've been through Measurable Solutions at one time or another over the past couple of decades, Mike is now the face of Measurable Solutions. Thank you for coming on, Mike. I appreciate you doing so.

Thank you for having me. I'm excited.

You've got a great expanding clinic in Virginia. In talking with you in the past, you've had some successful exit actions in terms of your marketing strategies and whatnot. I want to get to that, but I wanted to learn a little bit about you and your professional path. What got you to where you are now? Would you mind sharing it?

I started out as a physical therapist many years ago. I was a therapist for quite a long time, but I got started in therapy probably a lot as everybody else did. I wanted to help people. I had some injuries myself in high school and in college and it led me down that path. I was trying to decide between being an athletic trainer or a physical therapist. I had some physical therapy issues and I fell in love with it. I'll be honest, I never truly had any inspirations to be a business owner when I started out. I talked to a lot of guys and they come out of school knowing they want to own their own practice by the time they’ve been out for a couple of years. I never had that interest on my part. Physical therapy was a lot different then. I went to work for a company that I had been to the place where I had been a patient. I knew a couple of the therapists that were there. I had a good relationship with them. They helped me to grow skill-wise early on in my career. We got bought by a large hospital system, and I ended up somehow in management and not a hospital system. Maybe I got tricked into it.

I was the Outpatient Regional Head of about 37 different outpatient therapy centers up and down the different parts of the East Coast hospital system. I don't know how I get into that because it wasn't the direction I wanted to go. In the several years that I did that, I will honestly tell you that I never learned a single thing about running a business. I was responsible for all these places, who got hired and who worked when, but nobody ever taught me how to run a business. One day I said, “I am not happy with what I'm doing. I'm not happy working for this big conglomerate. I feel like I'm being told how to do everything.” I pretty much said, “The first opportunity that comes up, I want to get out.”

I mentioned that to my boss at the time. I said, “Anytime any one of these physical therapy centers in this area where I live here in Virginia is up for sale, let me know because I want to buy it.” Lo and behold, a few months later, Jane called me up. She said, “We're going to need to close a couple of places. Are you interested in any of them?” I said, “I sure am.” It fell into my lap so it's on my lap. I knew nothing about running a practice. There I was. All of a sudden I owned a practice. That was in 2005. A few days later, my wife and I bought a new house. A few months later, my daughter was born. A lot of things happened in a short period of time.

Here I am, I'm doing well. It was me at the time. I started to realize that I didn't want to be small. I wanted to help as many people as I could. I was in an area that was growing a lot. New doctors are coming in and things like that. I started to figure, “I got this. I can do this. I've run all these other places.” I started almost grasping at straws and pulling things out of the sky. Sometimes it worked and sometimes it didn't. Healthcare was a lot different back then. We got reimbursed a lot better and there weren't all of the authorization and restrictions that there are now. As those things started to creep in, I wasn't sure anymore what to do. I was starting to have some struggles. You mentioned Measurable Solutions. I was a client of them as well, that's where I found them. I started to learn how to run a business and that's what's become successful for me to the point where I've grown my business significantly.

What led you to reach out to Measurable Solutions in the first place or decide to get some help? What's intriguing is that you had all these years of management experience, yet you didn't learn how to run a business and you would assume that it'd be an easy transition for you to be successful in an outpatient clinic, which is a story itself. What led you? Was there a turning point where you're like, “I need to get on top of this. I need to find something else?” Is there a backstory behind that?

People don't buy what you do, they buy why you do it because they perceive how dedicated you are to what you do. Click To Tweet

Definitely, there is. Around 2011 to 2012, at least in my area, it's where a lot of physicians were starting to open their own PT practices. There were a couple of big companies that came into the area at the time, HealthSouth Physiotherapy came into the area. They started to open or buy a lot of clinics. I've run these outpatient centers, but I ran them underneath the guys in the management of this hospital system that I was part of. Here I am, I'm on my own. I don't know how to compete against HealthSouth Physiotherapy or PTs that are opening their own practice. I felt like I needed some help to help me to survive that period of time. That's when I reached out. That's what's been the impetus for me growing and being successful over the course of the last several years. We've expanded over 600% in terms of size and volume. It started from 2011 to 2012, where I was scared of what might happen if I didn't have a better plan in place to compete against these big guys that were coming in.

I don't know if the environment is all that different nowadays for new practice owners. Whether it's physicians that are taking their therapy services in-house if they haven't already done so or hospital networks buying up or larger nationally-run private equity firms or publicly-traded physical therapy companies that are coming and buying some of the smaller clinics. It's happening all over the place. Even though it's a little bit different than your situation, I'm sure there is a similar environment now where there are owners who aren't sure what their future looks like, reimbursements are going to go down, authorizations are going to be a lot harder, all that kind of stuff. There are plenty of questions out there. That's my mantra. You’ve got to reach out and get some help. Reach out, step out, and network. You’ve got to reach out and find somebody to give you some of that business training.

That's why I love your show because it exposes people to many other opportunities. Many other people had been through the same things. I was at PPS, I was talking to a lot of new guys that are coming out. They've been out for a couple of years and they're experiencing the same things. Here in my area, I forget about the fact that there is not even a primary care physician in my area anymore that doesn't own his or her own PT practice. I forget about that because I've got assistance ingrained. It works so well. As I was talking to some guys, it's happening all over the place pretty much no matter where you are from Alaska to Florida. It's the same situation.

It was you as a physical therapist when you initially got started. Where are you at now? How many providers do you have on staff? How many locations do you have?

I always like to look back on that. It truly was just me. I didn't have any office staff. I didn't have a tech. I didn't have anything. It was me. I answered the phone. I collected payments. I sent the claims to the insurance company. I treated the patients. I cleaned the tables. I always like to look back on that. Here's where we're at now. We had our fourteenth clinician PT that started. In PT/PTA, we have five athletic trainers that work for us as well. I wouldn't be doing it fair if I gave you a number, but we have a large number of the front office staff that includes billing and things like that. We'd probably have 8 or 9 people. We have a total of 38 or 39 employees now. We're all in one location. I would say I have six clinics. They're all in one building.

Every time we've needed or wanted to expand, we've been able to take on additional space in the building that we're in. It’s one of the things that I learned when I moved to this building back in 2007. We're in this direct center of the county and you have to drive through us to get to anywhere you go in our area. Rather than opening another place over here and another one over there, it's always worked economies of scale for us to take on another 2,000 square feet and turn it into that. We took on 2,000 square feet. We haven't knocked down the wall yet. We don't need the space yet, but it puts us at over 16,000 square feet. That's why I say I have six clinics, but they're all in one. Every time we do so, we've got to hire new office staff, new clinical staff and that's how we've grown.

I've always been envious of that. It's nice to say that I've got 4, 6, 10, 12 locations, but I've always been envious of you because you've got one location and a bunch of providers knocking it out. It’s economies of scale. You got immediate visual oversight of what's going on in the clinic and everyone is in connection with each other. It's easy to develop your culture and a lot of that goes on well. Your story is awesome but I want to talk about what ramped up your numbers. What were some of the successful actions? There's one particular program that I want to delve in with you about. What do you think some of the successful actions had been for you in terms of expanding your numbers?

I would say there are two pieces. One is getting more new patients in the door. I would sum that up as saying like marketing and promoting. Both internal and external things and how we look at and how we address a patient from the time they start to the time they finish, getting them to what I would call a successful discharge. Those are the two pieces where every year we'd rather bring in more new patients. We've expanded that way and/or we've tightened down our systems and made a much better process. We improved the process to make sure that we're keeping patients all the way to a successful discharge. Those two things have been the biggest driving factors in our expansion, especially over the last several years.

PTO 74 | Internal Marketing Programs
Internal Marketing Programs: We should address a patient from the time they start all the way to a successful discharge.

 

I love what you said there that you added tightening up the processes because many times, I find that many clinics if they're going through some tough times don't necessarily need a lot of new patients. What you find is that they have holes in the bucket, holes in the ship, however you want to analogize that, but they don't have the structural integrity to maintain the patients to get them through their full plan of care to a successful discharge. If you can shore up those holes and maintain the integrity of your system so there are people getting through to discharge successfully. You don't meet a lot of new patients, but when you do start getting new patients, you start seeing tremendous growth. That's what you see that you shored up your systems. I do have to put a plugin here. Your wife has been on the show before, her name is Dee Bills. She owns Front Office GURU. I recommend you go back and read her episode and when she recognized that she spent more than a year in fortifying the front office systems in your clinic to do exactly what we're talking about.

I am glad you mentioned that. I was going to say that in the year 2014, we had five fewer new patients came in the door in 2014 but it’s when we implemented and instilled all of the processes that she now teaches people out in Front Office GURU. We grew 31% in the year of 2014 both in collections and patient visits because we shored up all those holes. That's a great point to the fact that you don't need more new patients all of the time, you need to be sometimes look at improving your systems. We had fewer new patients over the course of fourteen from the previous year thirteen. We grew considerably because we shored up and plugged all those holes with all of the things that she now goes off and teaches other people. I'm lucky enough to be able to have learned that along the way with her. We continue to put it into play now.

I can't imagine how much money, how well that hit your bottom line, your net profits in that regard because your expenses were probably about the same. I did a show with Heidi Jannenga and they do their annual WebPT State of Rehab Survey Report. They found that the average small clinic loses about $150,000 per year in gross revenue. They haven't shored up their systems in there and patients essentially aren't completing their plans of care successful.

Think about it, you need to get a patient that finishes two visits, finishes themselves, two visits before they should have. You multiply that by however many patients there are. That's a ton of visits. It's a ton of money that we're losing as business owners.

What I want to talk to you is you've focused on and all of us are out there, “I need to get physician relationships, visits and referrals.” Those are super important. It's important to have those relationships with the doctors in the community, but you've been successful with your internal referral programs. Do you mind sharing with the audience a little bit about that and what you do?

We have done a good job in my opinion. We've done a good job of building relationships with patients that are current and how we get them to refer patients. You can call it a patient referral program, but anybody can give out a card that says, “Refer a patient or I'll give you a gift card to target if you refer me a patient.” I live hard on this philosophy of people who don't buy what you do, they buy why you do it. They perceive how dedicated you are to what you do. You talked about the culture before. You're creating a culture where patients want to share that with their friends and their families. It goes a lot into educating the patient. In Virginia, we have some loose direct access laws, which do help us. I would tell you, I'm working with a client in Texas that has some restrictive direct access laws. This is working gangbusters for them.

If you educate your patients on when they can come to you, how they can refer their family, friends, and you teach your staff how to have the right conversations, that program comes into play. I'll give you an example. If I'm working with a patient and I am talking to him about, “What do you do for work?” “I work around the corner at Oracle.” “Tell me something about the guys that you work with.” “We all sit around in these cubicles all day. We're all on our computers all day.” Let's say this guy is here for his knee because he hurt it running, but I will start to ask questions like, “Anybody at work ever complaining about their arms hurting them, their elbows hurting them, their necks hurting them?”

He was like, “We were having this conversation. We've got to figure out some way because at the end of the day, on Friday, our necks are always stiff and sore.” There's a light bulb for me. I'm going to educate him on what he should be saying to those five guys that he sits in a cubicle with. Before you know it, 2 or 3 of them have become patients in a short period of time while that guy that I was treating is still here. It's a matter of how do I educate him to go back to the office and educate those people so that the internal referral is walking in the door before that guy has ever been discharged. He's replaced himself 2 or 3 times over. That cycle keeps ongoing.

Train, drill, and practice. Click To Tweet

I love it because that takes it to another level. I love it because you're basing it upon your higher purpose. Whereas our internal referral program in the past, it was a little bit more like, “Who else do you know that's in pain?” Inevitably you might know somebody that has some issues with this, that or the other. It was surprising to me how many patients would sit there as we're working on their knees and they'd ask us, “Do you guys work with low back pain?” That's 75% of my patient load. Patients still don't know what we do essentially. We have to educate them on how we can provide value to them. For those patients who are coming with their knees, you ask them, “Are they having issues with their backs? Tell us about your family or whatnot.” You look for opportunities where you can instruct not only them but also instruct them on how they can help or guide their friends and family over to you by the value you provide.

I realized that it's a matter of I had to change my mindset that it was okay for me to tell them what type of patient to send me and when to send me that. If I'm having a conversation with a parent and they're like, “What'd you do this weekend?” “I was with my kids. My kid had this soccer tournament.” “Does anybody ever get hurt on the field?” “All the time.” “Here's what I want you to do.” I had to change my mindset. “The next time somebody gets hurt, I want you to give them this card. We're going to write your name on it because I want you to get credit for it. Once you give them this card, I want you to tell them about the experience that you're having in therapy. What do you like about therapy right now?” “I liked the fact that every time I come in, you guys remember my name and you remember what we did last time. You always want to know things. You're progressing me.” “I want you to share that with that child's parents.”

It helps that process of I'm educating that patient on what to do because they don't know that we treat backs because they're here for their knee. They don't know that somebody else can walk in off the street because they came to us from a referral from a physician. All of those points where we can educate them on, it might come into play when they're in therapy. It might come into play a few weeks from now, but we all are going to come in contact with somebody that's in some level of discomfort. I want them to be able to go, “I had a great experience. You should go see those guys.” For us, that was a big part of it.

That's a great example of how you're not handing over the card saying, “If you know anybody, you can get a free movie ticket if you pass them along to us.” I love how you give them the words, the verbiage to use when they're in that situation so that they do feel comfortable. Maybe they don't use the exact words, but they know the feeling that you're trying to portray it. Through them, they can express that feeling in those words to someone who needs physical therapy, honestly. What have been some of the benefits of that? Have you seen a significant amount of growth simply by pushing the internal referral program?

Yes, we've tracked a lot of different statistics. The ones that we track is how many of our new patients on a weekly basis are coming from what we call patient referrals, which would be that internal referral program. On an annual basis up through the end of the third quarter, after the end of September 2019, about 38% of our new patients had come from referrals from other people, which is only second to new patients coming to us off of the internet, social media. It's three times the amount of referrals that we get from physicians, we're getting patients referring family, friends. It's been successful. When you look at it if I used to get three new patients from that, let's say 27 is what we had. If I get 27 new patients from patient referrals, then let's think about how much that's going to help things to expand. It takes us back to the previous topic we were talking about.

If I referred you to someplace, you're going to go with you're already sold. I don't have to sell you on your plan of care. You're going to want to stay because your wife said it was a great place. You're going to do what I tell you because your wife said that. It helps that process much easier. I always tell my staff, “Wouldn't you rather treat the friends of the patients that you liked, then roll the dice on that guy that walks in off the street and you don't know anything about him? You already know that patient because they work with Joe at Oracle. You already know things about them. You already have things in common.” It's much easier to treat that patient. Put that energy into educating them on how to refer somebody.

You use the words well and I'm sure you established a great referral program. How do you get the other providers on your team to do the same thing, to have the same words, to use the same energy? It's one thing to do it as the owner because you own that program and process, but how do you get that to extrapolate into the rest of the team, even the front desk?

This is the message that when you ask me, what is the one thing that's been most successful for you across all aspects of your business? It would be what I call drilling or training. We drill and we train all the time. I'll use it as an analogy. The World Series is finished. Washington Nationals, I'm not a Nationals fan even though I live right here in Washington DC. Let's say I was, I'm a Yankees fan, but nonetheless those guys train year-round. They'll take a couple of weeks off, but even on a day where there's a game, they're in the batting cage before the game. Why? They're going to get 27 pitches or so over the course of the game, but yet they're still practicing that. I take the same philosophy with my clinicians, with my front office staff.

PTO 74 | Internal Marketing Programs
Internal Marketing Programs: You don't need more new patients all of the time. Sometimes you need to look at improving your systems.

 

We need to practice. I have to recognize that I didn't get good at having a patient referral program in the first few years I was a clinician. I probably was horrible at it back then. As the business owner, I've perfected that skill, which is what helped me to be successful as a business owner. As to help my staff, all of them, you have to be as successful as that. It comes to training. We train, drill and practice. How would you ask me for a referral? I wouldn't say, “Do you know anybody I know?” I would train them, drill with them, and practice with them how to have that conversation so that it flows They want to get those referrals. They don't know how to go about the process. They'll be like, “Have this referral card and bring it.” They'll get back to whatever they were doing because the conversation doesn't flow naturally. It's practice.

To get into the weeds a little bit, are you doing this one on one? Are you doing it as a group? I mistakenly immediately went and said that you're training this with the providers, but you're dealing with your whole staff. The entire staff should be on board with this internal referral program because they know the value that Loudoun Sports Therapy provides to the community. You shouldn't be holding that back. How often are you doing these drilling or training sessions?

I'll try to break it down for you this way. If we're talking about the referral program, it starts on day one. If you are a new employee, you're training and drilling on the referral program every single day. Whether you work at the front desk, you’re a tech, you’re a PT. There's some semblance of drilling on that every single day, five days a week as part of from day one of starting. Even my people that had been here from 5 to 8 years, they're still drilling a minimum of one time a week for 30 minutes on that one aspect.

We do drills on a lot of different things, but that is the key thing that everybody does. No matter what you do, everybody's drilling on that a minimum of 30 minutes a week, at least one time a week. There may be other things that you're drilling on. Every staff member for us drills a minimum total of 60 minutes a week. That's the inside of their 40 hours a week. It's not an addition. If you're newer, more of your 40 hour week is going to be on drilling. If you're older, you've been here longer, it's still that minimum of an hour and 30 minutes of that hour is always on the referral program.

Do you do that over the course of a year? You guys have become experts then at getting referrals from patients.

Yes, it’s the same thing. Think about the baseball players. They're still in the batting cage all the time. It's funny, we're having this conversation. My youngest daughter who's sixteen, who still is in high school, she's the only one that we have left at home. She is interviewing for a job here. She's going through the same process. She's worked there since she was eight, but she's still interviewing for a job. It'd be a position at the front desk. She came home, she had the interview process. She's like, “I won't say their name, but I might want to drill with Sally a little bit more because she wasn't as good at talking about the referral program as I think she should be.” There's always been a joke. My daughter has always said that she's the Deputy CEO of Loudoun Sports Therapy. It was interesting to see how somebody who's grown-up seeing that and to be able to see. She’s somebody who's been here for a couple of weeks and that's a new employee that she was talking about. She’s somebody that flows well but still has room for improvement on that.

You guys will not only train on the internal referral programming. Essentially, the goal with the training then is to get the referrals from the patient or to pass along the card simply. What is the goal of each training session?

The goal of the training session would be that they have an increased level of confidence in being able to help the patients to have a realization of somebody that's out there that maybe we could help. We're not looking for them to give us their name and their phone number. That's not the process we're following. If that's what somebody is doing, that's perfectly fine. What we're looking for is for them to have the realization. I dragged my trashcan down to the street and I was talking to my neighbor. He's like, “My knee has been bothering me.” What I want is for that patient to realize that's somebody that they could refer to us.” It's drilling with the staff member to have that conversation, help the patient to have that realization, and come to the conclusion of, “I don't have to send them here, shouldn't I? Do you guys do these?” “Yes, we do.” “Do you have something I could give them?” “I have this card. You could give them the card” We have a card that says referral card on it. We'll write the patient's name on it so they get credit for it. We'll send them a thank you, but we don't do anything else.

The goal of the training session is to have an increased level of confidence in being able to help the patients. Click To Tweet

You say you're getting 38% of your patients from this internal referral program. I'm assuming that with all the physicians on physical therapy clinics in your area, you don't get a lot of physician referrals. What's your percentage there?

It is 11%.

Where are you getting a majority of your patients from at this time?

If we look at beyond the patient referral program, what I would classify to be like social media, the internet. It's social media, internet, and the patient referral program tied together. We have an expectation that every patient who successfully completes therapy is going to give us a success story. Do an online review for us. We average about 13 to 14 online reviews a week between Facebook and Google. That's hard. It's an extension of that internal review or referral program. They give us that review.

The discharge patients give us that review so that somebody out in the community sees that, has that reality with it and reaches out. The majority of our patients, we've been successful in building the use of that direct access through that patient referral program. Patients come to us off the street, they'll see something that we put up on Facebook or an email that we send out or something that we mail out. It’s a whole own separate entity. That's the number one driving force. The number two driving force for new patients is the patient referral program.

Physician referrals have declined over the course of a number of years. The study, a couple of years ago, it declined 50% between 2010 and 2018. It's dependent on us to change our marketing strategy. Don't forsake your physician relationships, those are valuable. You always want to be able to the physicians that these patients are saying, but you’ve got to consider direct to consumer marketing is the way you need to go. If you're outside of the internal, the patients are already there. I'm assuming you've got emails or newsletters that are going out to past patients and you're constantly mining that group because that's an ever-expanding group. You've got the internal referral program that gets you some immediate patients based on the patients that are in the clinic. When it comes to social media, are you doing some Facebook ads? Are you simply having those patients post on social media?

We're doing both. For example, that patient that is discharged now, they'll do an online review for us. They'll put their success story up. We'll share that. We'll like that. They'll share that and like that with their friends with that piece. We are doing a whole semblance of things online. We do run ads on Facebook, Instagram, etc. Most of what we're doing is unpaid. Most of what we're doing is I would term to be organic. It's not following the organic definition of Facebook. We post five things a day on Facebook about different problems. It falls back to the notion of if I educate people that there is a problem, how the problem is affecting them, that there's a solution for it, they're going to be much more likely to take action because they understand what it will do for them to take action.

It goes back to that mantra of people don't buy what you're doing. They buy why you're doing it. I'm constantly putting out content that helps people to see that it's not normal at the age of 45 to have knee pain, despite where we might think in society. In society, we think, “It's okay because I'm getting older.” It shouldn't be that way. It doesn't have to be that way. “Here are some things you might be having problems with going up and downstairs, sitting to watch a movie. There's a solution to it.” After they see that a certain number of times, they will start to take action. We'll tie that success story into it. “Here's Joe who had knee problems. He came to us and here are his results.” That's part of that whole process.

PTO 74 | Internal Marketing Programs
internal Marketing Programs: When the discharged patients give us that review, somebody out in the community who sees that will be reaching out.

 

The majority of what we're doing when it comes to getting new patients off of social media, internet, isn't down that paid avenue as much as it's down the continue to educate them and give them good content and information. They will make that decision to take action in a relatively short period of time. I hadn't changed my mindset. I used to think, “One post a week was enough.” Now, I said, “We do a minimum of five a day and a minimum of two emails a day.” That's a minimum. If we just hired a new clinician and we're trying to fill their schedule, then it's 7 to 8 things a day and 4 to 5 emails a day. I had to change my mindset, but following that same philosophy.

Who's creating all that content?

We have all of our clinical staff create all of that content. We do all of our own social media stuff in-house. It's a requirement. It's an expectation. If you're a clinician that works for us, you're going to produce one blog every three weeks and one vlog every five weeks. We're constantly creating that content internally. I have full-time promotions, people that work for us as part of our staff. They're employed here, but that's her job as she does social media stuff. She's taking those blogs that she's getting, she's turning them into content, throwing a picture with it, putting it up online, deciding what to do with it. It's getting that stuff out, but all our clinicians are producing all of that.

Do you find you're getting a lot of patients that say, “I found you guys on Facebook?” Are you getting some of that?

When we look at it if I were to turn around here. If I'm looking at my referrals that came from online, 63% of our new patients came to us of some form of online, internet, social media.

I haven't talked to a lot of successful PT owners that have had as much success as you have when it comes to the internet and social media work. Do you attribute that sheer volume on the consistency of your posting?

It comes down to three things. One is the volume. It is the quantity of things that we're putting out. Number two, it's the quality of what we're putting out. We're not putting out, “Come to Loudoun Sports Therapy.” We're putting out, “Here's a problem. Here's how therapy can help. By the way, at Loudoun Sports therapy, we treat that.” We're telling a story to the patients that they come to have a realization that there's a problem. There's a solution to it. The third thing that I'd say that helped us to drive that as that I've spent a lot of time. The benefit of me being able to truly be an owner and not have to worry about being a physical therapist is I've been able to dedicate my time and hire staff who have the same desire to learn a lot about that avenue of marketing and promoting and using social media.

I've become a pseudo expert in marketing and promotion. That's one of the things that I do with Measurable Solutions is helping to pass that information on to other practice owners so that they can have the same results. It is something that's been successful for us. I talked to a lot of practice owners who tried it but it didn't work. I'll say it's because they didn't put their full attention and energy on it. They were paying somebody that's also marketing for the restaurant down the street, writing a blog for them about something. It's always driven towards, “Come to Loudoun Sports Therapy.” That’s a no-no. “Go to physical therapy. By the way, Loudoun Sports Therapy does the things that we're talking about.”

People need to see something an average of twelve or more times before they take action on it. Click To Tweet

That's one thing I know about myself is that I'm not the creative type, content creation is like nails on a chalkboard. Inevitably you probably have somebody on your team that would probably love to have that responsibility to do that. You have shown by the fact that your providers are doing content creation, have created a culture, and a group of people that are willing, wanting and anxious to provide that.

I'd say it's a lot later. Back to the drilling on teaching a patient how they can refer to others. A lot of times, we'd get very all worked up about a blog has to be this big fancy thing with a lot of stats and a lot of stuff. It's making it simple for that staff member, “If you were standing in line at the grocery store and the person in front of you kept rubbing their neck, what would you talk to that person about for 2.5 minutes? Go write that down. That's a blog. Making it something that's much simpler because that's the type of relationship we should have with our potential patients. Don't be all fancy and super-duper hyper stuff. Be simple and basic.”

They will have that realization if they see it enough. You've got to have stuff out there and enough content. The same thing with the patient on the patient referrals side, the internal referrals, you can't mention it one time. You've got to be like, “When you went back to work, did you talk to any of those guys that were complaining about their neck pain?” “No, I didn't.” You're like, “You have to keep coming back to that point.” It's the same thing. It's everything in quantity will give you what you're looking for later on.

I love how you brought that back around full circle to the internal referral program. The one-time conversation isn't sufficient. There need to be followups, there needs to be, “As you walked around, have you noticed other people with a similar condition? What are your friends and family like?

I might've been talking to you about the guys you sit at work with you had lunch with, but then you're telling me about the soccer game. You're talking about raking leaves with your neighbors. All of those things are opportunities where I keep ingraining in you. I keep having this relatively same conversation, but I keep ingraining in you how you can refer to other people. I don't just have it one time. It's like a shoulder that's frozen. I don't mobilize it one time and it's all better. I've got to mobilize it twelve times and it starts getting better. It's the same thing with getting somebody to refer, getting those referrals in. A lot of times we get wrapped into, “I tried that. We tried it three times over the course of three months.” You have that conversation twice with a patient on day five. On day fifteen, they didn't do what you needed him to do.

I read a study that said, “On this day and age of social media, we need to see something an average of twelve or more times before we'll take action on it.” It changed my mindset. If I'm putting out a blog a week, a couple of weeks from now, maybe somebody will go, “I should do that.” The reality is if they're only seeing it once a week, they forgot about it by the time they see it next week. The same is true for patients. If I had a conversation with you about referring your wife, but I don't ask the next time, “How's your wife doing?” You forgot that we had a conversation. I’ve got to have that conversation with you multiple times for you to go, “I'm going to have the conversation with her and get her off my back at a minimum.” You’ve got to hear and see something twelve times before you take action on it.

That changes my mindset hearing you say that. It's understandable because, in the past, my refrain growing up was that someone's got to hear it three times for it to sink in. If you consider the decreased attention span of people nowadays and how easily distracted they are. You tell me once and I'm going to forget that by the time I scroll up to the next thing on LinkedIn or Facebook. If I see it a number of times and especially, more than three times over the course of even a couple of days, then it starts sinking in. I can see where twelve is coming from.

If you watch football games, if you watch an NFL game in a span of 3.5 hours, how many times do you see the exact same commercial? Not the commercial for Bud Light or for Ford trucks. It's the exact same commercial. It's the same philosophy. You've got to see it many times before you're like, “I need that truck.” That's the society we live in.

PTO 74 | Internal Marketing Programs
Internal Marketing Programs: When you educate people that there is a problem, how the problem is affecting them, and that there's a solution for it, they are much more likely to take action.

 

Thanks for sharing so much about some of the successful actions that you're doing with your clinic. It's evident in the numbers that you have now and the growth that you guys have seen. If someone wanted to reach out to you to pick your brain, ask about Measurable Solutions, even get in touch with Dee, how would they get in touch with you?

That's the point I love about where I am in my career now is that I get a chance to help other practice owners. I am so much about helping the private practice owner to survive in this day and age of big corporations. Anybody that wants to reach out to me, I would love to sit down, chat and help in any way I can. The best way to get in touch with me is to send me a text, shoot me an email, or leave me a voicemail. I'll give you my cell phone number. It's (703) 470-5995. One of the great things about me, having built this business to my clinic is I've been able to give back to Measurable Solutions that was helpful for me.

They taught me a ton of the basics of these things that I've applied and talked about. I've been able to join their team. I'm the President of Measurable Solutions now. The best email to reach me at is my email for them. That would be Mike@FortisBusinessSolutions.com. Send me an email. I'm happy to figure out a time that we could talk or anything like that. I am always about being able to help people because I want private practices to survive. I do not want us to get eaten up by physicians and corporations. I'd love to help anybody that's out there that wants more information.

Thank you for your time. I appreciate it, Mike. It was great. There's a ton of value. Thank you.

You're welcome. Thank you.

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About Mike Bills, PT

PTO 74 | Internal Marketing ProgramsMike Bills is the Owner and CEO of Loudoun Sports Therapy Center in Sterling VA. He started his practice in 2005 and did everything: answered the phone, treated patients, billed the insurance, etc. Since that time he has grown his practice by over 10 times. He now has a staff of well over 20 people, including 14 clinicians and a facility size of over 10,000 square feet. It was always Mike’s goal to have the time and ability to manage his business and not work in it and he has fulfilled that goal as he is the true CEO and no longer treats patients. Another goal Mike had was to be able to help other PT’s have the Freedom they deserved from their practice.

Mike was a client of Measurable Solutions where he learned how to truly manage a private practice and where he learned how to truly be the CEO. This is where he learned the basis for all of the systems that he uses in his practice that have helped him to be so successful. Recently Mike was named the President of Measurable Solutions and is now able to fulfill that goal of helping other private practice PT’s have the same success as him. If it weren’t for the perseverance and drive over the years to build a successful business this never would have been a reality for him. Marketing is one of the most important pillars of a private practice and I have worked hard to develop systems that continuously help my practice to grow and thrive despite the time of year or whatever else is happening in my community. I am happy to be invited onto the podcast to share just a fraction of what has helped us be so successful.

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PTO 73 | Secured Financial Freedom

 

There is nothing more comforting than knowing that you are financially secure for the future. Bringing in a trusted expert from Econologics Financial Advisors, Eric Miller gets into the mindset, attitude, and strategic plans you need in place to secure your wealth for the future and for your household. Eric and Econologics have been working as financial advisors to hundreds of private practice owners over the past decade. Thus, they know some of the pitfalls that we share when it comes to our finances and what it takes for owners to become financially free. Eric goes beyond the investments and portfolios and sets you up with the right mindset and financial purpose and goals that are in line with your retirement plans. Secure your household and make your clinic the vehicle by which you achieve your financial goals in this episode.

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Listen to the podcast here:

Navigating The Path To Financial Freedom With Eric Miller Of Econologics

I get to talk about money, one of my favorite topics. One of the reasons why I got into business was to have more freedom and security for my future. I decided to bring on Eric Miller of Econologics. If you remember, we had Christopher Music of Econologics on. I've been working with them for a little over a year. I do have to have full disclosure that I have an interest in their performance. I've also been a happy client. The reason why I like Econologics is not only do I like their perspective on financial planning but also the amount of communication they provide. If you follow my episode with Frank Cawley, we talked about important financial indicators like KPIs, reports and developing a financial team. Those things are all important. What I get into with Eric is more the mindset, attitude and strategic plans that you need to have in place in order to secure your wealth for the future and for your household. Important items to consider, this is all about securing the household and making our clinics the vehicle by which we achieve our financial goals. Let's get to the episode.

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I've got Eric Miller, Chief Financial Advisor of Econologics joining me to talk about one of my favorite topics, money. Thanks for coming on, Eric. I appreciate it.

My pleasure, Nate.

Can you share with us a little bit about your experience as a financial advisor and your practice or work with private practice owners? What's got you to this point?

Long story short, I am a financial advisor and I've been in the financial industry for about twenty years. I grew up in Toledo, Ohio. I moved to Columbus, Ohio in 1990. The funny thing is I get so jealous of practice owners because a lot of you knew what you were going to do when you're 8 to 10 years old. I was 29 years old before I knew what I wanted to do. I always had an interest in money. For some reason, it was an area that always attracted me. I didn't study the subject when I went to college. When I got out of college, I worked for a mutual fund company selling 401(k)s and managed accounts.

I started to get introduced to what financial advisors did. By and large, what I found out was although they were benevolent and they wanted to do a good job, it was mostly an accumulation of assets. That's what they did. They didn't focus on, “How do we change someone's financial condition?” It was, “How much money can we manage?” I met a friend that said, “I'm going to start a financial planning company down in Florida. Do you want to join me?” At that point, I had a house, a dog and a girlfriend. I knew that was my purpose at that point in time. Like many people, I was like, “If I'm going to do it, I better do it right now,” and I jumped. I drove down there and got rid of that life. This was in 2008. Do you remember what was happening in 2008?

Bad timing.

Your practice is what drives your personal wealth. It is the main money artery that most private practice owners have. Click To Tweet

It was a global meltdown. The stock market was down 50% and banks overlent to everyone. It was chaos. It was the worst time you could think of to start a financial planning company. We were thinking to ourselves, “We have to do something differently. We can't rely upon all these financial institutions for people to get financially independent.” We had to come up with a system where the business owner himself could be put back into control of his financial destiny. That's what we worked on. We started working with private practice physical therapists. It was the first type of clientele that we worked with. We developed our system of showing a business owner how he can be in charge of his financial future as opposed to putting it in somebody else's hands. How does he do that? How does he use the business as the engine to do that? We focused a lot of our efforts on that. We started working with veterinarians and other private practitioners, but our core is working with private practice physical therapists.

It’s cool that you niched down like that. You've had so much experience over the past decade focused mainly on physical therapists, so you'll know some of the ins and outs of our dilemmas, issues and whatnot.

That's the fun part about it. Your practice is what drives your personal wealth, for most of you. You don't always want to be in that financial condition. That's where most of the money comes from. That's the main money artery that most private practice owners have. If you're advising someone, you better know something about their business that you're going to help them with their money. We do spend a lot of time on that.

You've been working for over twenty years. For the past decade of working specifically with physical therapists, what are some of the things that you would recommend they consider as they're trying to establish a better financial picture or financial condition? We have plenty of display vehicles out there whether that's the traditional 401(k)s, IRAs and stuff. What is your advice to some of the physical therapists out there?

The main thing that we try to get across is number one, you have to treat your household like a business. What I mean by that is that a lot of physical therapists get trapped in the practice. They're there to serve the practice as opposed to the practice being there to serve them. The first thing that we try to teach private practice owners is that you are not there to serve this practice. It's there to serve your household. When you start doing financial planning, it starts with the household. What are the goals and purposes of the household? How can the practice benefit that? What we do is to teach them your point of where you're controlling things. If you look like a company like Facebook. Facebook is the parent company. It owns 80 companies underneath it. Those companies are there to serve Facebook, not the other way around. Our households are no different. Your household, the Nathan Shields’ household, all your kids and your beautiful wife, that's the parent company. That's where everything flows to for the benefit of that.

It's a paradigm shift. Many owners need to make it because they get trapped inside of the company. I espouse that all the time. That's why I want people to reach out and step out of the business so they can work on the business. It's the same thing when you're talking about financials. It's a mindset shift instead of, “What do I need to do inside this business to keep it afloat?” No, you're saying step out and look at it from the household perspective and say, “What does my household need to survive, sustain and prepare for the future? What can the company do for me in order to achieve my household goals?”

PTO 73 | Secured Financial Freedom
Secured Financial Freedom: A good owner tries to build the practice to the highest value that it possibly can provide for the household.

 

When you have that mindset shift right there, it's amazing what happens. You start to put the correct systems in the business that allow you to extract out of it so you can operate from the household level as opposed to being stuck in the business. When you have a plan, you start to know your identity. When you're in the business, you have certain roles that you have to play. You have your owner role, executive role and practitioner role. Not a lot of people are wearing that owner role like they should. That's where we teach people how to do that.

They conflate executive or administrative work with ownership work. Those are two different things. They maybe can hire an office manager to take over some of those administrative/executive functions and responsibilities. That doesn't absolve you from still being an owner, setting up your company appropriately, strategizing and making sure that it funds the household. This is on top of funding itself, so it can sustain your household.

You hit it right on the head. You can pick two of those roles. You can be an owner/executive or you can be an owner/practitioner, but you're always going to be an owner. You have to make sure that you have that mindset of what an owner does. What does an owner do? They make sure that the practice is creating maximum value for themselves and the household. They're trying to build the practice to the highest value that it possibly can provide for the household. That's what a good owner does.

When you sit in the ownership seat, you also never lose the Chief Financial Officer seat at our size. You're still the CFO. You can't delegate that and you shouldn't. You need to be on top of your cashflow.

You absolutely do. The biggest mistake that I see a lot of practice owners do is they stop paying attention to their money. For whatever reason, that's the one thing that you can never do. Money loves attention. It's like a two-year-old at the mall. If you take your attention off a two-year-old at the mall, you have no idea where they're going to end up. Things get lost and your money is no different. When you take your attention off of your money lines, even for a split second, it's amazing how the money will disperse everywhere. Being a good CFO doesn't mean that you have to know how to do spreadsheets and all those technical things. It means that you have to be a good controller of money. It means that you have to be responsible with money. You have to know the basics of money. It isn't that complex at all. It takes some training that you didn't get in PT school.

I can say that my financial situation improved when I started holding my CPA responsible for teaching me what a P&L was about, what a balance sheet looks like, and cashflow reports. I said, “I need to meet with you monthly so you can show me all these things.” I got my own education about finances. On top of that, I started meeting regularly with my biller, which I didn't do before. I was reviewing some of the billing reports and asking them to tell me, “What does this mean? What does this say? What should I know about this, that or the other?” That's when my ship started tightening up or when I started plugging some holes in that bucket. I could see the difference in finances.

When you have a plan, you start to know your identity. Click To Tweet

All you were doing is putting your attention in an area that maybe you didn't confront for a while. One of the things that happen to a lot of practice owners is there's a lot of financial terminology that people don't understand and I totally get that. It's an easy area to say, “I don't want to confront this.” You need to dig into it and have some key metrics. A big thing, especially from the household perspective, is making sure that you have measurements or statistics to track your overall financial condition. It's not that hard to do. That's an obstacle that I see as well. A lot of people don't have correct financial statistics that they use to measure the kind of progress that they're supposed to be making.

A lot of people like looking at account statements. You look at your 401(k) statement and see how your mutual funds are doing. “I see that my bank account is a little bit bigger than it was from the week before and that's okay.” These are some of the things that I've asked people, “What do you use to measure your financial progress?” It's crazy some of the answers that I get. You have to look at that and have a list of metrics that can gauge the condition of the household if you're going to run it like a business. If you’re going to do that, you’ve got to do it professionally.

As people are trying to walk that path towards financial freedom or simply improving their financial situation, what are some highlights or actions that they can take in order to do that?

One of the biggest things is that you have to have a target. The first thing would be like, “What's the financial target that I want to achieve?” I created this chart called the Seven Zones of Financial Freedom. I wanted to make sure that people realize, “What financial condition am I in? What does that mean from a statistical point of view? What financial condition am I trying to get to?” That's defined by how much income I’m making, what my overall net worth is, how much ratio of my good debt versus my bad debt, how many income streams does my household have? These are things that you can look at and you can measure. The first thing would be like, “What financial zone do I want to get into?”

Regardless of what it is, personally, for a practice owner that is in control of your financial destiny, that can create as much value as you want to in your marketplace. If you want to be in a condition where you don't have to have concerns about money, your overall financial target has to be at least $7 million to $10 million of total assets. That to me would be a fairly safe financial condition to get into. It doesn't mean you have to save $7 million. When you look at the value of your business, maybe your real estate or other endeavors that you get into, that's the target you should be shooting for. That's a big thing because we haven't been taught to have that point of view. It's been like, “Let's accumulate a couple of million dollars in a 401(k) plan and let's hope that we don't run out of money.” That's not financial freedom.

As we get started at a young age, we think that retirement goal is so far off that it's not feasible to consider that down the road. The more attention you pay to it, maybe you get a little accelerant and you can get closer to that goal faster than you think. It doesn’t have to be all in your clinic. It could be on other vehicles but there's no reason why you can't accumulate those kinds of assets.

PTO 73 | Secured Financial Freedom
Secured Financial Freedom: There are so many opportunities out there to create a practice that you want to that there's no reason that you should restrict yourself at all.

 

The wealth accumulation is almost like a hockey stick graph or a grind. When you’re trying to create an owner independent practice, you're trying to put these things in and you're not seeing these huge results, then all of a sudden over a two or three-year period, you see these massive results. Wealth building is the same way. You're doing the same repetitive and boring things that you would do and you're like, “I don't know if I'm making a lot of progress.” It accelerates towards the end. The other thing would be the time frame to get into a financially independent state. It doesn't need to take 25 to 30 years to do that. You should be able to do that within 7 to 10 years if you're concentrating on your main money source, which is your practice and building that up.

Are there some things out there that you hear financial advisors recommend that you'd say, “That’s probably not the way you should go?”

To me, it's more of a mindset than the recommendations because I found that every investment vehicle has its place. It's the utilization of it and how you're applying it to your situation. There's not a bad investment, aside from someone trying to rip you off. There's some workability to retirement plans, managed accounts, life insurance or annuities. It would be like, “What's your strategy first?” That would be the first thing I would start with, “What’s your overall strategy?” I'll give you an example of what our strategy is for most of our clients. I have an acronym for it. I call it PREP. It stands for Produce income and be profitable in your business. That's the first target. Second, make sure that you are setting up an automatic and systematic way that you're retaining cashflow from the business to the household. Eradicate all bad waste like interest, cost and debt. Protect your assets from any kind of loss including taxes and lawsuits. PREP, that's a strategy right there. If you focus on those four things, you're going to have a mountain of success.

Anything else that falls below that would be tactics. “Do I buy this policy or that policy?” “Do I put money in this investment or that investment?” It's all part of an overall strategy. A lot of practice owners get caught up in tactics as opposed to strategy. This money market accounts yielding 0.5. Should I put my money on this one or should I put this one that's dealing 1.2? They put their attention on things that aren't going to move the needle on their financial condition. We spent a lot of time thinking about what's the strategy first and then tactics. It was Sun Tzu who had a great quote that he said, “Strategy without tactics is the slowest route to victory, but tactics without strategy is the noise before defeat.” I thought that was important. I know when someone's about ready to lose financially when all they want to do is talk about investment products and performance of something. They’re all about tactics, they're not about the overall strategy. It's interesting.

Do you see a typical pattern when it comes to physical therapy owners? Are they focused on tactics more so? Is there something about physical therapy owners that's unique and that you have to fix even if it's mindset or strategy?

For the most part, physical therapy owners are healthcare professionals. They love to help people. A lot of them are trying to push themselves out of the practitioner role in trying to be better executives and owners. I see that in more so in the physical therapy field than I do in veterinary or dentist. People that are veterinarians or dentists, they love being practitioners. Not that physical therapists don't like being practitioners, but they seem to have the business acumen. They can see what could happen if I get a lot of physical therapists here working under me and I grow this business and I scale it. I can create something that has a mountain of value to it. From a mindset standpoint, I still see a bit of scarcity and some of the decisions that practitioners make. Money is scarce and it’s either this or that. It's never both. A lot of what we're trying to do is trying to make sure that they look at it from that perspective, “I don't have to do this or that I can do both.” How much money does the practice need to produce in order to do that and making sure that I keep my profitability level at a certain amount so I can do that?

Money loves attention like a two-year-old at the mall. If you take your attention off them, you have no idea where they're going to end up. Click To Tweet

That's true for most physical therapy owners. There's a scarcity mindset. There's a lot of fear involved in what we do. They also tend to be a significant amount of burnout from what I can tell, so that's why maybe there's that transition out of patient care more so. You don't see a lot of older physical therapists in the profession.

That's funny that you should say that because a lot of the burnout comes from an industry where you're relying upon insurance reimburses. A lot of the reimbursements are going down and the profit is being eroded away. The burnout comes from the fact that there's a lack of exchange there. You're putting all this work and you’re putting all this effort in. You're seeing 10% or 7% profit margins and that would tax me. You can go buy a Puerto Rican bond for 6% and not have the headache of employees and regulators coming in there and saying, “You overbuilt here.” “You didn't code this correctly.” I can see where it taxes and makes a practice owner burnout. Once you solve that profitability issue adding additional services that maybe you didn't before and you get that backup, that's where you see people live it up a little bit.

As you've worked with private practice owners and you've seen them in all kinds of different financial conditions, what are some of the successful actions that they're taking? We talked about the mindset and we talked about strategy. We talked a little bit about tactics. Anything else that you recognize what helps that struggling maybe not struggling? How do those physical therapists improve their financial condition on top of those things?

A lot of it starts with their own personal training. When I say personal training, personal financial education training. Know what some of the basics are of money. Let's not be scared about it. Profit and loss statement is not something that is difficult to understand. That's not even that important to know. You should know about it but knowing some of the basics of money. You need to seek advice from people that are qualified to give it. That's a basic of money. Staying out of bad debt and that would be another basic principle. Things that they probably inherently know but are having a tough time applying. To me, it always starts with making sure that you have your attention on your main money artery.

I call it the main money artery, which is your practice. There's this idea that you have to go out and create all these different income streams that are true for the most part. You definitely want to have multiple income streams flowing into your household. You want to make sure that you have one that's flowing like the Mississippi first. If you can get that one going and setup system, the money then flows to the household to create other income streams. That's probably the most successful action that I've seen. There are some of the most successful owners that I've seen have gotten their practice to a point where it's cashflowing. They set up the system where they take a portion of their business cashflow and automatically every single week set it aside in the household to help create other income streams in the household. That's been the most successful action that we've done with practice owners. If I can get someone to do that, it's game over. They start to feel like, “This practice is starting to serve me as opposed to the other way around.”

PTO 73 | Secured Financial Freedom
Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones

I had Christopher Music on and he talked about setting aside 10% of your revenue every month, maybe weekly, but at least monthly. That blew my mind. That's the first time I'd heard that concept and I thought, “If I had set aside 10% of my gross revenues every month for the past sixteen years or whatever I own my clinic, I'd be in a much different situation.” It was cool how he laid it out if you set aside that like it's an expense. Christopher mentions this, you guys mention it. I've read it in Profit First, a popular financial advisory book by Mike Michalowicz. You set aside the Profit First that becomes like an expense line. Inevitably your business grows to meet it.

You have to. We operate with the concept that I know that a business is going to try to spend every flipping dollar that it makes and then some. You know that going in and you see that when you look at practice owners over and over again. I see that pattern. I know business is going to try to spend every dollar that makes. I also know that it will make the exact amount of money it thinks it needs to make to survive. Know those two things, so when you incorporate that 10% as an actual expense and you put it in, you have to do it on a gradient though. If you try to do it too fast, it could cause some problems but if you do it on a gradient, it’s amazing what happens. Things change overnight because you've incorporated that expense. The business thinks it's an expense, but it's simply the accumulation of a reserve pool for the household. If I could tell your whole audience if they did that one thing, they would never regret that ever.

It will change their financials entirely, especially if you look down the road. It's going to be a completely different condition.

Most of the practice owners that are doing $1 million of revenue a year, they're like, “We’ll do the math on that 10%.” “$100,000 a year?” I’m like, “Yes.” When you look at that, that's your owner's compensation. If you're a good owner, that's your owner's compensation. You deserve it. I always tell owners, “If Medicare comes in to audit you, who are they going to audit? They're going to audit you. They're going to audit the practice and you own that.” If you have a lawsuit who gets served. Whose names are on all the notes of any of the practice acquisition loans? It's you. You took all the risks to put this thing there by God, you deserve to get that 10%. That's a reward for you.

Sometimes I have to convince people. It was the funniest thing when we first started, I thought that would be the easiest thing that I could possibly do. I'm like, “There's nobody that would say no to that.” It's the hardest thing to get a practice owner to decide. I knew we were onto something when we started that because I’ve got the most push back when I started saying, “We need to put this money away.” “We can’t do it.” There’s no way.” “There's no way the business is yet too many expenses.” “I can't do it.” We figured out a way that they could do it, so it doesn't cave them in. Once we got that in, everything clicked right after that event for the business owner. It was fascinating.

It's interesting how it also changes the mindset. It changes the energy around the person as you have them focus on their money lines, their lifeblood, their main artery, whatever you want to call it. Once they put their attention on that, the energy changes. They take on the control that they didn't seem to have before and they seem a little bit more focused.

When you do that, it enhances your financial awareness and then it gives you confidence. That's the most important thing in any industry, you have confidence. When you have confidence, you make better decisions. You slow things down a little bit. You control time like an athlete that you see that's competent and what they do, they have so much confidence. They can control time. Most physical therapists are good at doing that from a training standpoint, but on business and an ownership standpoint, they're not as good at that until they get trained to do it. It's establishing financial confidence that does increase your confidence by a high degree.

When you have confidence, you make better decisions. Click To Tweet

As you bring on physical therapy owner as a client, is that something you work on them with? What was your typical work look like that might set you apart from other financial advisors?

The first thing that we do is we give them a detailed financial scene that we want them to get to. We define what your ideal financial condition would look like. I don't think that a lot of advisors do that. They'll say, “Let’s save enough for retirement.” They don't give them a clear definition of what their financial condition looks like. We've created a road map where we encompass all the different component parts of your financial life. That’s the thing that differentiates us as well. Your financial life, the body is made up of several different systems. You have the circulatory system, the respiratory system, the endocrine system and all these different systems.

There are nine financial systems that make up your household, from asset protection to estate planning to income planning to debt and credit to tax optimization. There are several different systems and our job as financial advisors is to make sure that all of those systems are operating at their optimum level for every one of our practice owners. Whereas a lot of financial advisors will focus on the investment side. That's 1/9 of your overall financial scene. We put people's awareness on that and say, “Maybe let’s not only look at your investments while they're important. Let's not put all the focus on that.”

I have to say that I work with Econologics and I have enjoyed my experience with them especially compared to other financial advisors that I’ve worked within the past. Simply by the fact that you guys are in communication with me which is typical of the financial advisors that I've had in the past. I wish I had started working with you earlier. To give voice to the first exercise you're talking about. My wife and I went through that, setting a target you talked about $7 million to $10 million. That might seem to be a lofty way out there for some people. You also had us break it down to, “What do I need to be making per month in order to get to those goals?” That gives you a little bit more concrete and current number that can work on. I have that number, and my wife and I have those numbers in our head, “We can have this kind of lifestyle if it makes this much per month, but we can have this much better lifestyle to make this much per month. Let's try to reach for that.” That guides us on a lot of the decisions we're making as much as it pertains to income, investments, and whatnot. That's valuable.

Thank you. When you break it down, I know sometimes we set big targets for practice owners. You will be sometimes a little bit like, “There's no way I'll be able to do that.” When you break it down to like, “We don't have to do all this now.” What can we start? Where can we start? We build upon that. Financial planning is a set of boring repetitive activities. As you continue to do them, you see little mini results. All of a sudden, it’s like, “Boom.” It's amazing how it works. Traditional financial planning is like, “If you put $10,000 away for the next 25 years then you'll have blank amount.” Real-life doesn't work that way. People change, business owners change. Their confidence and business changes. The production of their business changes the industry that you're in. There's so much money pouring in private physical therapy.

There are so many opportunities out there to create a practice that you want to that there's no reason that you should restrict yourself at all. To your point, set big targets and big goals. Let's work backward on what are the actions that are going to lead to get there. When you get the numbers down, it's not that much. It's not that hard. It's not that much and that's where a lot of people appreciate you. You need to have a written plan not only a proposal of, “Let's put X amount of dollars and this investment strategy and X amount of dollars and that and this investment strategy.” That's a proposal. A plan is like, “These are the sequence of actions that I need to take in order to accomplish this.” Most people are operating on financial proposals and not financial plans and that I've seen.

The plan goes back to your ideal financial scene. I want to invest in my children's education. I'm going to have this much at retirement so I can live the way I want. I want to invest in these kinds of vehicles. I want to live mortgage-free. Those are the things that you start from and work on.

That's where it starts. What are the financial goals of the household? Which a lot of people have done. It digs into, how are we going to measure that? That's where I've seen, in our industry there hasn't been a lot of good financial metrics that measure the condition of the households and how we integrate the business into that as well. We have seventeen different financial diagnostic statistics that we look at. We can show someone, “Here's a statistic that you need to look at and we want to improve.” It goes above looking at the performance of an account. It's something that will help someone change their overall condition.

Is there anything else you want to add to the financial stuff that we hardly get into it or what?

I don't even know. This is getting fun.

I know we’ll definitely have you on again, so we have to save a little bit.

For the most part, the keys I want to leave people with is, no matter what your financial condition is, good, bad or ugly or no matter where you're at in your life cycle, whether you're still growing your practice, whether you're mid-career or whether you're thinking about exiting out. You can always do something to change your trajectory. You can always do something to change your financial condition. The sooner that people can realize that their household is the parent company. Make sure that you're wearing that identity of a Chief Financial Officer assuming that beingness, there's a good book called Atomic Habits on if you ever read it before.

No matter what your financial condition is, you can always do something to change your trajectory. Click To Tweet

I've heard a couple of people mention it. I need to read it.

The main point of that was, the actions aren't that hard. It's who you have to become if you want to be successful at something. You have to become the identity of that person. Your financial conditions are no different. You have to assume the identity of someone that's responsible with money, that knows how to acquire and control money, and that can expand money. That's an identity. That's the Chief Financial Officer identity. If you can assume that identity, understand that and wear that, the actions are easy. It's not that hard. It's don't spend more than what you make. Take 10% of what your practice does and set it aside, invest prudently. The basics are not that hard. You have to assume that identity of the person that is going to direct this whole thing.

I love that idea because you are exactly where you think you should be. There's an internal dialogue that's always going on. If you assume or if you take on the mantle of, “I am good with my money and my business makes money for me,” then that's what will happen. If you are careless with money and you think, “I spend more than I make. I need to do better with my money.” That's exactly where you will be.

It's 100%. I have created what's called a Chart of Money Attitudes. I don't know if you've seen it or not. Every single day I’ll say certain things to myself like, “I'm a creator of money. My financial decisions are naturally right. I'm fully responsible with money. I want enormous wealth and I want others to have wealth too.” All these affirmations, things that I'll say to myself every single day because I want to make sure that my attitude towards money, which if you want to look at it, this is where it starts. What's your attitude towards money? If you have the attitude of, “I can't have money. Money is scarce. I'm terrible with money. It always disperses,” you're going be bad with money. You need to give yourself a checkup from the neck up every once in a while. When it starts with your money, that’s a key thing. Make sure your attitude, in terms of money, is in good shape and get out of some of the fixed ideas that you have or get out of some of the following gurus and around. You don't need a guru. You need a guide. The attitude comes from other places too, from parents and the experiences that they’ve seen and all kinds of things. We can get deep on this one.

It brings us full circle. It's where we started. It all starts with your mindset and your attitude with money and recognizing that the business works for you instead of you working for the business.

You hit it right on the head.

If people wanted to reach out to you, Eric, how do they do that? What do you have coming up?

We have a three-day training academy for private practice owners. We built our system for private practice owners. We don't work with engineers or teachers or any other of those types of vocations. We work with private practice owners and we built our financial planning specifically for them. We also create a financial planning education system where we teach them the basics of how to increase the value of their business and then how to make sure that they turn those business profits into personal wealth. If they want to contact us you can definitely start by going to our website which is EconologicsFinancialAdvisors.com. You can email me directly at Eric@Econologics.com.

We created 100 question assessments that will give you a snapshot of where you stand in your personal finances. I would recommend that if anybody has any uncertainties, confusion, or I don't know in regard to their personal finances or curious. Everyone's curious about their credit score. What's my credit score? We've created an assessment that will give you a financial score. If people want to go to our website, it's called the Financial Prosperity Index. They could click on to that and it will take them right to that assessment. They can take the assessment. We will give you a free 30-minute strategy session where you can ask us anything you want in the subject of money and personal finances anything at all. As long as you take that assessment, then I'll assure you that you'll get that free 30 minutes or longer depending on how long it takes.

Thanks for coming on. We'll have to have you on again because I know you've got more to share for private practice owners.

We'll keep it on topic next time. We’ve got a lot of different places right there.

It was good. I love it and like I said, I love talking money.

It's all good.

Thanks for your time. Thanks, Nathan.

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About Eric Miller

PTO 73 | Secured Financial FreedomEric Miller Has been in the financial planning industry for over 20 years. He’s a co-owner of Econologics Financial Advisors – awarded an Inc. 5000 honoree for 2019.

As the Chief Financial Advisor for the firm, Eric has had the good fortune to have over 10,000 financial conversations with private practice owners in various healthcare industry and helped guide them into a more optimum financial condition using a proven system.

 

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PTO 72 | Billing In-House Or Outsourcing

 

It's an age-old question for PT owners - should I have my own billing department or outsource it? It's a dilemma that each PT will go through at some point. Let's get the answers from billing veteran Amy Sparks. Amy has 20+ years of medical and PT-specific billing experience and has a firm grasp of what it takes for an in-house billing department to run smoothly. IF you have the right people and IF you can monitor and manage them regularly (weekly and monthly meetings), then in-house billing may be right for you. But IF you outsource your billing, you still need to monitor, manage, and demand regular reporting. Make your decision to go in-house or outsource but never abdicate your responsibility to stay on top of your cash flow.

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Listen to the podcast here:

Bringing Billing In-House Or Outsourcing: The Pros And Cons With Amy Sparks

I get to talk with Amy Sparks. She is the Billing Account Manager out of Star Physical Therapy clinics in New Orleans. We're discussing whether or not to bring your billing in-house or to outsource your billing. After my discussion with Amy and based on my personal experience, I personally believe that in-house billing is the best way to go, but only if you have a couple of things in place, only if you have these two things. Number one, you've got to have the right person with the right personality type. The best billers that I've had seen billing and collections as a reflection of them personally. They take it personally if people don't pay, whether it's $5 or $500, they're in the pursuit of that money. They're willing to confront anybody that's not willing to pay, whether it's insurance companies or patients. They've got to be able to hold those conversations and demand payment when it's appropriate. The second thing is you've got to be able to have the time and the bandwidth to monitor and review and check up on the reports of the billing department that they provide you.

You've got to step out of treatment. Take the time on a weekly and a monthly basis to review billing reports with the billing supervisor, whether that's in house or outsourced to track your money. Whatever time you take away from patient care to review billing will come back in spades both immediately and in the future. That's your money, that's your cashflow, that's the lifeblood of your clinic and you've got to stay on top of it or else it will leak out. We talked about some of the reports, some of the KPIs that you'll want to review on a weekly, a monthly basis. Ultimately, the billing department did what's best for me when I demanded the most out of it. When I found the right person, I would talk to them about my expectations for the KPIs and they went along with it. I also talked about the reports that I wanted to see and they went along with it and created those reports and even added some statistics on top of it to show their performance and help them track the performance of people that they managed.

When you work in synergy like that and demand more out of the billing and collections, your billing and collections will improve. Your cashflow will improve. Those clinics that are growing have a heavy, solid, strong billing department. Those companies that are floundering typically also have a floundering billing department. We talk a lot about the ins and outs and the pros and cons of in-house versus outsource billing, some of the questions that you should ask if you are going to bring your collections in-house and some of the expectations you should have if you are going to outsource your billing. Let's get to that interview.

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I've got Amy Sparks. She is the Billing and Account Manager out of Star PT Clinics based out of New Orleans. They have eight locations. I came upon Amy because she wrote an article in Impact Magazine regarding in-house billing versus outsource the billing, what you should do and how to determine what if you should do either one. I'm excited to do this because it's a common question for all PT practice owners. First of all, Amy, thank you for coming on to the podcast. I appreciate it.

No problem. Thank you for having me.

Tell us a little bit about you, the experience that you have with physical therapy and billing in particular. How did you get to the point where you are now?

I was raised in New Orleans. I actually got involved in billing by accident about many years ago and I can't believe it's been that long. I started in billing for outpatient dialysis. From there, I ended up working at health insurance. I got to take those phone calls all day. I got involved as the biller for an OB-GYN doctor. About a few years ago, I got a job at an outpatient physical therapy clinic. That was my first experience in billing for physical therapy. I've been here at Star for two years.

Did you notice this significant difference in the billing between those other medical professionals and physical therapy?

If you billed for any sort of health care facility before, you can bill for physical therapy. Click To Tweet

Other than the coding, no. The codes are different, but pretty much the rules in the game are exactly the same.

I asked that because a lot of PT owners might be looking for that billing person. I never knew, is it important that they have physical therapy-specific experience? Any healthcare experience is beneficial and there's not much difference, but you're telling us it’s not that different. 

The CPT codes vary, but the rules of the game stayed the same. If you billed for any healthcare facility before you can build physical therapy.

I liked how you talked about the typical storyline that physical therapy owners go through in the article. You talked about a story that I'm very familiar with and a lot of other physical therapy owners are familiar with. Did you start with maybe a dedicated staff member or someone like that who is a rockstar? Maybe they want to do things on their own or maybe they start with an outsource billing company. What's the path that you typically see that you mentioned in the article?

Typically, what I usually see is when someone with a physical therapy clinic is starting out, they will hire somebody they think is a rockstar or even a family member or something, thinking, “Our patient load isn't that crazy right now. This person can handle this.” What ends up happening is they end up growing. Once they grow, they realize either they’re not so much of a rock star or this person was great when we were seeing twenty patients a week, but now that we're seeing 100 patients a week, it's too much for them. They'll end up either outsourcing to a billing company or trying to hire someone they think is better equipped for the job.

That usually goes a long way and based on your experience, I can share my experience as well, but outsourcing to a billing company, what are some of the pitfalls with that?

Some of the pitfalls with that is if it's a larger billing company, I don't think they can devote as much time as they should basically to your AR and your claims and stuff like that. If I have 200 other customers, they don't devote that amount of time and they're trying to get to that basic level, "We said we would get you 80%. That's where you're at." We're not going to go for the extra, even though it would be easy to. This is the same thing for in-house. You're at the mercy of who you hire in a way. People can look great on paper. They can interview like a rock star. When you get them actually to put their money where their mouth is, so to speak, they don't know half of what you thought they did.

You see that no matter whether you're doing it in-house or outsourcing your billing, you're never quite sure who you're playing with. When it's in-house, you do have some control there or more control at least because you can hire according to your values and hire someone that's aligned with you. You also can hone in on the customer service aspect of it that you don't have a lot of control over when you're outsourcing. One of the issues we had with outsourcing was that we had someone who was a jerk on the phone to these people and they were like, “That's not us. That's not our values. We could control that a little bit more when it was in-house.

I was going to say too because the person's right there, you can see how they spend their day. If you wanted to check in on them, you can hear how they talk to your customers, how they talk to insurance companies. That way you have more control of, “Is this what kind of person we want doing this for us? Are they giving us a bad reputation and we don't even know about it?”

PTO 72 | Billing In-House Or Outsourcing
Billing In-House Or Outsourcing: One of the pitfalls of a larger billing company is that they can’t devote as much time as they should to your AR and your claims because they have 250 other clients.

 

Unfortunately, that can be the last impression that they have of your clinic. They're no longer being seen in physical therapy and you don't have any contact with them. If they're doing something 3, 4, 6 months later that could be negative, that impacts you in a bad way.

Absolutely, it does. I always say the clinician and the billing department are basically in a relationship of a good cop, bad cop. The clinicians are the good cop, the people in billing are the bad cops always. We're good with that. We're fine with that. We're the ones who are going to take the bullets from your patients and stuff like that as far as getting of claims paid and such. We got that going on, but at the same time you have to keep a level of professionalism. You have to be mindful of what the owners want and what their values are. You can't overstep that and can go rogue with that as far as dealing with patients because you get problems with that. With in-house, you have more control over that because you get to see that more on a day to day plus you're right there. Your patients are right there. If they had a bad experience, trust me, the clinicians are going to be the first one to know about it.

It's also important to note that as you're managing the billing department from an owner's perspective, it's so important to manage the reports. When you have someone in-house, you can generate those reports and create them in a way that you want to see those important numbers, the KPIs and whatnot, getting them from an outsource billing company. Sometimes I've had a difficult time getting those reports. I have a hard time meeting up with them to talk to them about the reports or individual cases.

We're leading down the road towards the benefits of an in-house billing department. Some of the cons for an outsource billing department and we'll get to that because there are some benefits to an outsource billing department and not everyone's ready for an in-house billing department. As you manage your cashflow and as you manage your money when it is in-house, you have greater control. You can manage it appropriately. You can dig down on individual cases very readily. You can set up meeting times at appropriate times for both parties to work it out well. There is a huge benefit to that. That is difficult when you're outsourcing.

You don't have the freedom of meeting convenient times for you. You're at their mercy. If you have questions, you might be waiting a minute to get your answers because you don't have the person right there readily available to answer the questions for you. It depends. If you're starting out and you want to focus on growing your business and if you have the patient traffic coming through your doors already then maybe you do want it in-house because you want to focus on this. There are pros and cons to both. It depends on really where you're at. Honestly, the patient flow has a lot to do with it as well. If you have the patient numbers and where you're at in your business and what you're looking for. It depends.

It's almost like a seesaw. I like how you explained the cycle that some clinics go through, they'll outsource and they're not happy with the collections rate or how they're being representative of patients so they bring it in-house thinking they have a solid person who can do that and "save them money." Maybe the billing isn't as good as it should be because they don't have the experience and the knowhow. Maybe they have to consider, “We need to find another EMR as better billing software.” It's the seesaw battle. What I liked about how you broke it down is how to determine if you're ready for in house billing to ask the questions. If it's truly right for me at this time to have an in-house billing department, these are the questions I need to ask and answer. Let's go over those a little bit.

If you're considering doing in-house billing, we definitely want to have dedicated staff members who have a good work ethic, who know how billing works, who understand coding, who basically looks at your denials and say, "I need to fix this.” Also, they have the ability to find the right people to staff your billing department as well because that is a huge area. Hire somebody and you might think they're great and might take you 3 to 6 months to realize that this person's not great at all. The good thing about the billing is probably the only job that will always tell on you.

The numbers don't lie. 

The numbers don't lie and you can't hide that you don't know what you're doing or you're not doing your job in billing. You might be able to pull it off for a month or so, but eventually it's going to tell on you.

People can look great on paper. They can interview like a rockstar. When you get them to put their money where their mouth is, they don't know half of what you thought they did. Click To Tweet

You're saying you have to have someone who's not only educated but dedicated to billing. Maybe they're not full-time if your numbers don't match up. They need to have separated segregated time to do billing, only billing, focus on that and then also be capable of being a manager. As you grow, that billing department is also going to grow. That person is going to move from being the biller to the billing manager and maybe not touching everything but having to oversee somebody else.

As you grow, as a building manager, you have to know how to delegate. If you don't delegate, you will live swamped, constantly feeling like you can't your head above water. You have to find people around you that you can trust. That you can tell to do something. They're going to do it how you want it done and let you know when it's done, that you can rely on. To me a very strong work ethic is as important as the knowledge you bring.

It's a certain personality type that succeeds in billing. I'm sure you've seen this and what I've seen is the people that are successful, they are going to get every penny and it's almost a personal assault. They take it personally when people don't pay. They have to be able to confront. If you're very passive and laid back and trying to be a nice guy, you're not going to do well in the billing department. You have to find someone who is able to confront these patients who have a balance and talk about money because it can be a sensitive subject. 

 I've always told clinicians even though it's one patient, we are dealing with two completely different personalities because you're getting the nice, "Help me please," and very friendly. I'm getting a different person because I'm trying to get money out of them. He might be the sweetest person in the world in clinic, we'll get him over here and they'll start yelling. It's the nature of the beast. You definitely have to have a person who is thick-skinned, someone who doesn't take things personally. We need somebody who has a great attention to detail. A lot of times you'll find things are denied because one digit is off. I need you to find that or somebody has to have a very strong attention to detail. When you're talking to a rep on the phone and insurance rep particularly when they try to tell your reason for denial, I'd say a good 50% of the time, that's not what it is. You're looking at it like, "No, that's how it is." "What you're telling me is wrong, I see that I've done that part." “I see this down here is not right.” If I could look at that and say, "Look at coding," and say, "This needs to be modified or this code needs to be changed." things like that. They have to have very good attention to detail, definitely.

Tell us a little bit about the reports system, the ability to meet, review reports and where your clinic is in that regard. How important that is to determine if you can do in-house billing? 

For example, I meet with the owner once a week and then we meet again at the end of the month after we close out that month. What he will do for example, is he'll do an analysis. He'll randomly pull ten patients and check to make sure that the follow-up on them is done according to our procedures. That pretty much everything he pulls randomly has been touched. It goes to figure if he's pulling ten patients and I see that three of them have not been touched in several months, then it's safe to say that you probably have a pattern there going throughout your clinic. We'll meet on that. We make sure everything balances out, paychecks, denials, adjustments and refunds. We go over all these reports at the end of the month to verify that nothing was written off.

It shouldn't have been that insurance reversed the payment, but it was a legitimate reversal. It wasn't, "We want to take our money back on this," things like that. It's like the check and balances system. Meanwhile, throughout the month I'll randomly pull an AR report, go through it and spot check it basically to see. I’ll make sure everything looks good, the girls are following up working denials and things like that as they should be. He spot-checks me. It's a system of checks and balances that we have in place. We will meet once a week. We email, "Can you meet at this time?" We set up a time. It's very convenient because like I said, I'm here in-house.

Especially if you're going to do the in-house billing, then it's necessary to recognize that you need to set aside the time to meet weekly and monthly to review weekly and monthly reports. You know what you're looking at as the owner. There are certain statistics that I'm sure he's going to review or certain categories that he wants to check out. Also, take the time to do some spot checking and follow up on it themselves. I think that's a great word of advice, but tell us a little bit about some of the key statistics that you're looking at maybe that you and your owner are looking at as you review some of the weekly or monthly reports. What are some of the top 3 or 4 statistics that you guys are reviewing?

One thing we look at is called the Accounts Receivable Conversion ratio. It’s called an ARC ratio. It's basically our total AR divided by the number of average number that we have built out per month. We'll take an average of the last three months, not including things like auto, attorney or people who are in collections obviously. We basically divide the AR by the average bill. We'd like that number to be less than 1.3. Basically saying that it takes us 1.3 months or less than 1.3 months to collect. That's basically what that tells us. We are much less than that actually. That's always a good thing as long as we stay below that number.

PTO 72 | Billing In-House Or Outsourcing
Billing In-House Or Outsourcing: If you're considering doing in-house billing, you need dedicated staff members who have good work ethic, know how billing works, understand coding, and have the ability to find the right people to staff your billing department.

 

It's great because we all know that the longer you let that money sit out there, the less likely you're going to receive it. You get pennies on the dollar the longer it stays out there. To keep that average within or 45 days is huge.

It also helps you as far as if there's a problem somewhere. For example, we monitor it every single month. If that number were to skyrocket from one month, the next we'd be like, "We have a problem here somewhere." Either an insurance began processing our claims wrong or we're not receiving payments somewhere or something's not right. It's also great with a monitor that everything should be steadily going down with that number. It's a good way to monitor and make sure I catch it early if there are any issues happening that maybe you're not aware of.

That's a monthly statistic that you follow and that's huge. What are some of the others that you follow?

Another one we follow, we call it the 90-plus. Basically what we do with that is we will take the AR 90-plus.

The AR aging report and whatever's in the 90 plus day range and above.

We'll divide that by the total AR and that gives this a percentage of basically AR that is over 90 days old. You want that to be less than 10% of your total AR.

When you come into a clinic that's bad or a clinic that’s in a bad situation, when it comes to collections, you'll see that statistic specifically be bad. To take it from there to under 10%, in my experience can take anywhere probably about six months at least to get down to a good range. That's where you're going to find some extra cash, but you're also going to lose a lot of money as that number gets larger. We used to actually bonus our biller based on her ability to keep that under 10%. Once she did that, then she essentially got a raise to continue to keep that under 10%.

Once you get it down there, it should be very easy to maintain, but I'm glad you brought that up because I think a lot of clinic owners, whether it be in PT or other areas of healthcare don't realize that if your AR looks bad, it's not going to get fixed overnight. It is going to take time for it to come down because it takes an insurance 30 days to process a claim and that's if it looks good. You have to keep in mind that it's not going to be an overnight thing. It will take a couple of months to get it down. Six months is probably very good timeline think about. If you're not seeing anything drastically improving in a month, don't freak out. It will be a slow and steady drop it took and you didn't get this bad AR overnight it's going to take at a time to come down. It's going to be a lot of fighting with the insurance because that is definitely something that has changed since I've started back in the day. It used to be a lot easier. You file a claim, the member ID is right and the birthday is right, they’ll get paid. Now, no.

Not so much.

The clinician and the billing department is a relationship of a good cop, bad cop. The clinicians are the good cops and the people in billing are the bad cops. Click To Tweet

There are two players I'm thinking of in particular that are good at the game. You've probably seen this yourself. For example, therapeutic activities. You build therapeutic activities with any other therapy exercises. There are two payers in particular that they will automatically always deny therapeutic activities even though it was built correctly. They'll deny it and that they want you to send in all this documentation and medical records. If they find your documentation is sufficient, then they'll pay it things like that, which is very time-consuming. You're left with this $50, $60 balance on your claim. They'll sit there for a few months because they will take their time with that. The frustrating part is that there was never anything wrong with it. We could have paid it from the get-go. It ends up on your AR longer than it should.

They know that if they simply deny it, then they'll save money. Most people won't take the time to appeal it. Especially in some of those cases where the outsource billing won't go after the extra $50. 

They'll say, “We're going to write this off,” and it can be a problem like that because those charges do add up. They don't want to devote the time. I can tell you from our standpoint, we've gotten to the point with that where we've had to basically create a letter of medical necessity template. We tailor that for each patient and it seems to be working. Prior to that, you'd go through sending in flow sheets, sending in medical records and waiting for those to tell you, "No, that's not enough." That is a team effort because we have to get the clinicians on-board like, “I need you to tell me exactly what you did every single minute.”

That can be difficult.

They're not crazy about it either obviously, because they know what they're doing.

What are some of the things people should look for if they are considering a billing company? What guidelines do you recommend? 

If you are looking for a billing company, you should look first at all your costs. I would say you should not pay any more than 6% to 9% of your collections. Also they should provide you with consistent reports to show you their performance like, "Here, look what we've done." They should also provide you with their policies regarding their workflow because like you said earlier, their policies, their way of doing things might not match up with your values. You need to have a clear idea of what their policies are regarding their workflow, how they handle things.

They should also be very transparent regarding how much time do I actually put into a claim as you ask. If I have one code that denies from $50, are you even going to try and fight for it? Are you going to suggest that we write it off and move on? That will give you an idea of how much time they're going to put into chasing, not just that claim but all of your claims. The insurance is hoping that you're going to give up. They think that if they hold you out for six months, you’ll be like, “I'm tired of this. Let's go. I'm going to write it off.”

One thing that also always brings up the red flag for me when it comes to dealing not just with billing companies but with any vendors is their willingness and ability to communicate. If I have to constantly search and ask for reports or feedback, that's a lot of wasted time and energy. I would like for them to take the initiative to provide those reports on a monthly basis. I've had to do that with billing companies in the past. I said, "At the beginning of each month, I want to see these reports come to me without me asking for them. Can you do that for me? If you're going to ever write off a balance, that needs to be cleared through me first.”

I don't even write off balances without getting the owner's approval first. I do think this is true for anybody, your support staff starts at the very front, your receptionist. I know a lot of people think that, "She just answers phones, schedules and appointments, whatever." She needs to have a great attention to detail because she's doing the data entry of this patient's information usually and not to mention she's your first point of contact for your patients. She's basically the face of your company when they walk in the door. It's important to understand that one wrong digit on a birthday or a member ID number will delay your claims payment for at least another 30 days. You have to have a strong person at the front. At least double-check what she put in, make sure the numbers are right. You need to have somebody very strong upfront as well. It's a whole group effort between the receptionist, the billing department and the clinicians.

PTO 72 | Billing In-House Or Outsourcing
Billing In-House Or Outsourcing: A lot of clinic owners, whether it be in PT or other areas of healthcare, don't realize that if your AR looks bad, it's not going to get fixed overnight.

 

One thing also to figure out with when you're considering outsourcing is how closely are they going to work with you on improving collection or billing performance. One benefit of having in-house billing is to say, "We're constantly getting denied for such and such code," like you're talking about, "We're constantly getting denied for therapeutic activities. Should we consider modifying our documentation so it’s built under therapeutic exercise and we don't have to go through all of this?" Of course you don't want to tell them how to treat, but you need to raise the awareness like, "We're spending a lot of time and effort on a code that's getting denied." If you have someone in-house, you can have that conversation. If you're going to outsource this, you need to make sure that you're having those same conversations and you need to make sure you're setting up time and the awareness that's expected. 

I agree and something you had mentioned was saying how you've had to chase down some of them out when you outsource to get your reports and stuff. An important thing to remember is not to sell yourself short with that because if that was happening in-house, you wouldn't tolerate that. You wouldn't tolerate having to chase down an employee to get a report. You would expect them to bring it to you. It’s the same thing with the outsourcing. You have what you expect and you shouldn't settle. If you're not getting what you need from this outsource billing company, I would say definitely you need to make a change, but you really shouldn't have to chase people down because you're paying them. They're not paying you. They work for you, so they're like any other employee.

If I have a question, I need you to answer it in a timely manner and you need to expect constant communication. There are many times that they need information from you or they're expecting information from you and you need either back to them. Because of that, sometimes I think we feel like we're working for them instead of the other way around. You need to remember that you're the owner, you can always change this person out. You can always fire your outsource billing companies. If they're not doing what you need them to do in terms of reports, meetings, communications, customer service on your behalf, you can always fire them and you need to find someone better.

There are too many companies out there. There are too many people out there with billing experience. There are companies that do outdoors that you shouldn't have to settle, if you're not getting what you want.

To give some of the owners a heads up, what is your experience when you do switch out of an outsource billing company to in-house? If you're moving from an in-house biller to another in-house biller because one got let go or whatnot. I'd say that to preface this is to say that when I've seen billers change whether going from outsourced to in-house, there can be a real blow to cashflow for about six months or so before you get back on your feet again. I think PT owners need to understand that they expect the transition like that might be good, but you're not going to see the benefits of it for 6 to 12 months and they have to be patient and stay on top of the metrics in the meantime. 

I know it's human nature. You want it now, but you have to keep in mind that the fact that your reason you're changing is that if it wasn't working the way it was going. More or less, you've gotten yourself or billing company has gotten you into a hole, if you will. You're not replacing them because they were doing a great job when your AR is low. You're replacing because they weren't doing what you needed or your AR, your cashflow is going down. It's a mess. Like any mess, it’s going to take time to clean up. As I said, you didn't get in this hole overnight. This took months to happen. It's going to take months to fix it. I know it's very frustrating for owners because they expect to see an improvement within the following month. It doesn't happen that way because keep in mind that insurances on average take 30 days to process a claim in itself. When they're going through cleaning up your AR, they're refiling all these claims, correcting them, refund insurance.

At best, you're looking at 30 days and that's not going to be for everything because at least half of that you're probably going to end up fighting for because the insurance doesn't want to pay. The worker's comp company doesn't want to pay it. They'll deny it for crazy things. Probably one is not timely, even when you send in proof of timely file. For example, you know how it prints on a HIPAA? If today's date would be 10, 18, and 19. I've had a particular insurance company deny saying that date of service was prior to the patient's date of birth. I realized that the patient was born in 54, they are reading the date of service as 1918 or 1919, not 2019. I'm like, "Are you kidding me? My health insurance is in 1919. My health insurance’s dead. What are you talking about?" I couldn't believe it. It blew my mind. This is hands down the worst denial I've ever seen in my life.

I want to talk to you a couple more questions simply because you are a billing manager now. You are working with billing people who work underneath and you oversee them. What are some of the recommendations that you can give the PT owners as they're working with a billing department, not a single person? If they're large enough to where they have two, maybe three people doing billing for them, what are some of the things you are looking for as a billing manager in your management of others? The separate duties, how do you organize your staff? 

I separate my staff. We have a person who bills out claims every day so she'll bill those up. She's also the person I have that works my insurance AR because she knows how to code. She's billing the claims out. She knows what to look for. She's very strong in that. Also, I call her my pit bull because she does not have any issue getting on the phone and fighting. I swear she fights like it is her own money and that's what I look for. That's what I love in a billing person. It's like, "I'm sorry I got mad." "No, don't be sorry, you got mad. I appreciate the fact that you act like that is coming out of your personal pocket, like this is your money."

I love that. I look for that. I look for a good work ethic. You don't want somebody that's constantly calling out because this, that or the other. Somebody who doesn't mind being on the phone, doesn't mind getting into the trenches as far as that goes to the insurance company and sitting there on the phone with them for 30 minutes fighting. Also on the flip side, I have another person, she does all of my patient payments, my attorney's cases and my patient AR. I have her do the patient payments because she's the one calling the patients to about bills. That's how I break it down. As I said, I oversee them, I spot check them and that's my checks and balances for them.

As you grow your business, you’re going to have a billing manager. You have to know how to delegate. If you don't delegate, you will live swamped 24/7. Click To Tweet

I have somebody who does the same thing for me. You need to have systems in place with reports. Checks and balances is a great thing. I do it to them and somebody does it to me. That's how we make sure that we're running officially, policies are being followed, procedures are being followed, everything's being done, how it should be. We have a system in place as far as patient collecting, “You do this and this,” and then you send them to collections if you've got nowhere. We made sure all the steps are being followed and things like that. It works. Prior, I've seen it done other ways. I didn't like it.

I've seen where they would say, "This person is going to handle these five insurances and then this person is going to handle these five insurances." Basically everybody’s got their hands in everything. I prefer to keep it separate. It flows better that way. You only have the same two people accountable for patients. You have the same two people accountable for insurance and that will never cross so there can never be, “He said, she said,” kind of a thing. All communication between the billing department and the receptionist needs to be via email because we have a paper trail that way again, “I told her this." “No one ever told me that.” It cuts out all the, “He said, she said.”

That's a great policy to have because the insurance or the billing department is all about paper documentation of everything they do. You might as well keep that as it pertains to communication with the front desk as well.

Also we have over 100 employees here, otherwise a lot of people are always emailing billing, which is fine. I prefer email because like I said, you have a paper trail and also you're not constantly getting that distraction on the phone. You take this phone call and by the time you're done with that, "What was I doing?" That kind of a thing. This way it's all in writing. You're not getting constantly distracted twenty times an hour or pulled away from what you're doing twenty times an hour to answer phone calls about, what about this? What about that?

We talked a little bit about when you consider an outsource billing company, their charges are typically somewhere between 6% to 9% of your revenues. What is your company's expectation as far as what the cost of your billing department is to the revenues of your company? 

We'd like to keep it between 3% to 5% maybe and it's toward the 3% honestly.

It gets like that when you're a larger company. For a guy that's smaller, if they're thinking that, “Maybe I can save some money, if I bring it in-house, they'd probably need to expect it's going to be closer to the 5%.” Maybe a little bit more and recognize maybe some of the benefits that go with it if it's running well. If it's not running well, then that billing department's going to cost you more. When a billing department is running well, you can expect it to be in a smaller clinic somewhere between 5% to 7% compared to the 6% to 9% that you would pay otherwise. You'd have to consider the benefits and the pros and cons of both.

We've had Star open eighteen years. We've had quite a significant amount of time to grow and expand and work out all the kinks. We're about 3%, but as I said, we're larger though. We've been around for a while, so I could definitely see where to expect that number to go up whether you're smaller or a newer clinic even.

You guys have been around a long time. You've got a ton of experience. If people wanted to reach out to you and maybe ask you questions or get your advice, are you open to that?

Absolutely, we actually love to mentor and advise new PTs, new clinic owners. I actually spoke to someone. I didn't know her but it was through the article and she was a clinician and she was just asking me questions about different things we thought she should do. One of the things I definitely want to preface to her was that as the clinician, you don't want to be involved as far as try to collect patient balances. You're the good guy. You're the helper. You need somebody to keep it that way. You need somebody to bigger fall guy basically and that's what we are. As I said, we're good with that but you definitely don't want to be both because you're on their side.

PTO 72 | Billing In-House Or Outsourcing
Billing In-House Or Outsourcing: If you’re looking for a billing company, you should not pay any more than 6%-9% of all your collections. They should also provide you with consistent reports to show you their performance and policies regarding their workflow.

 

You don't want to taint that in any way by bringing money into it basically. You definitely want to keep those two separate. As a clinician, you want to stay as far away from that as possible. You definitely need people for that. I was going to say that while you're starting out and it's new and you don't think you need this, that or the other because "We're new, we're starting out." That is one thing you would definitely need as a new clinician. You need somebody to handle that for you. Whether it be outsourced or whether it be in-house as a clinician, no matter how small you are you don't want to be that person.

If people had questions like that, how would they get in touch with you? 

They can email me. My email is Amy@StarPTClinics.com. Our owner for example, he's been practicing since ‘93 and he's a member of the editorial APTA board member. He loves to talk to other PTs and business owners like that. He loves to advise them. He loves to help them with any questions they may have or anything they might possibly need. He likes to help other PT clinicians grow and expand their business. That's what he's really trying to get into now. As part of that, something we would also like to do is possibly start billing for other PT clinics. You could go with an outsource you might not know too well or you have solid companies you can go for. You can go for that as my reputation and word of mouth.

You guys obviously have the systems in place, you know how to get things done. You've got a ton of experience behind you. It's one thing to go with an outsource billing company that might do a billing for all kinds of medical professions. Whereas you guys are PT-focused, PT-specific, you've got a couple of decades in the business based on your owner and the experience that you bring with it. You guys can bring a lot of value to those PT clinics that are looking to get things started to maybe outsource until they're ready to bring it in-house. 

We have all the systems in place, the reports, policies, checks and balances, you name it. Obviously it's been successful because Star itself has been open for eighteen years but we're still growing. We opened up our eight clinic and we still have plans to open more. It’s obviously successful. Our owner's been practicing PT since 1993. He loves helping, marketing and helping people grow and expand, showing new owners what to do. He's been through the trenches, he's been through the trial and errors of it all. He has seen it all because he's basically was his own test patient more or less.

What was his name?

His name is Matt Slimming.

We'll have to remember him.

If anybody wants to reach him, you can email me and we'll both be in touch with you.

Thanks again for your time, Amy. I really appreciate you sharing your wisdom.

No problem. If you need anything, give me an email.

Thank you very much.

Important Links:

About Amy Sparks

PTO 72 | Billing In-House Or OutsourcingAmy B. Sparks is the Billing Manager for Star Physical Therapy, the largest independent Physical Therapy group in the greater New Orleans area, with eight clinics and growing. Amy was born and raised in New Orleans. She began working in health insurance billing twenty years ago.

She has experience billing for several different types of healthcare providers and has also worked for Aetna Health Insurance, giving her experience on both sides of the industry.

 

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PTO 71 | Achieving Financial Goals

 

Freedom comes from making a healthy profit. Thus, on this episode, host Nathan Shields and guest Frank Cawley, PT discuss what it takes to establish a solid financial structure and improve profits in business. They tackle the important KPIs you need to track, the financial team you should have in place, the pros/cons of owning your office space, and the reports you need to review regularly. We're all in the PT ownership business in order to do things the way we want to do them and to make as much money as we want to make without depending on others. If we lose sight of our financials, then we're bound to lose our business altogether (or endure a lot of stress in the meantime). Take the time to monitor your finances regularly and your business will reward you with more money and freedom.

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Listen to the podcast here:

Financial Fundamentals: How To Achieve Your Financial Goals With Frank Cawley, PT

I'm talking about one of my favorite subjects and that is anything to do with money. I've got Frank Cawley, a physical therapist out of Pennsylvania on with me. We'd taken the opportunity to break down some basic financial fundamentals in regards to your physical therapy practice. If you feel like you've got a handle on things, maybe this is a good episode to compare what you're doing with Frank's recommendations as well as my experience. If you're new or feeling green in regards to your financials, maybe this is a good episode for you to take notes because we talk about KPIs, Key Performance Indicators and the statistics that you need to follow in your practice. We talked about the importance of renting versus owning the space that you're in. Also, the importance of developing your financial team as it were.

We go into a number of different things and it's great to talk about it. You might be able to tell that I get a little bit excited in this episode because I love talking about numbers. That's who I am. Vitally important, we have to make a profit in order to sustain ourselves in what we're trying to develop and obtain the dreams that we have either for our clinics, for our families or our individual selves. It all comes down to making a profit. Although we like to think we're a little bit more altruistic, we got to make money.

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I’ve got Frank Cawley, the CEO of Cawley Physical Therapy and Rehabilitation out of Northeast Pennsylvania. He’s successful. He’s got six locations going. He’s also the Cofounder of Next Level PT and Director of their AR and real estate acquisitions. I’m excited to bring him on because we’re going to talk about money. Frank, thank you for coming on.

Nathan, thank you for having me. I’m excited to be here. It’s a big honor.

Thank you for taking the time. If you don't mind sharing with the audience, what got you to six locations and where you're at? You've had a long history. If you don't mind sharing a professional snapshot of what got you to where you are at?

My wife and I started the PT business. She is not a physical therapist, but she was helping out with the business side of things. It was her and I. I graduated from Hahnemann University in 1999 and want to take on the world, treat everybody and get everybody better. I thought that's what was going to happen. I got out into the field and started treating people and enjoyed it. I started to understand a little bit more of the business aspect of things. Quite frankly, I never thought this was something that I'd be even possibly talking about, but my wife somehow someway convinced me, "You could do it yourself. I think that you'd be great at it." Lo and behold, as with most things, she was correct. We opened our first clinic in April of 2003 with the grand total of zero patients on the schedule for the first week. Thankfully through perseverance, hard work and support from my wife, family, friends and our communities, we started to evolve. We started with one clinic at that time and opened our last clinic in April of 2019.

We're very excited about that. That was our sixth clinic. We're seeing upwards of about 650 patients a week which we're very happy about. We'd like to say 650 satisfied and successful clients. We continue to look for ways to evolve and grow. We have a ten-year vision and mission of twenty clinics with hopeful of 2,000 patient visits per week and roughly 130 to 150 new patients per week, which is pretty amazing because we sit around a number of 130 to 150 new patients a month. Thinking of those numbers seems so unfathomable, but with time and with growth. I love to know what things would be looking like in ten years from now when I’m able to have a conversation with myself and see where we're at. We're anxious, excited and hopeful that we can meet those expectations.

I'm sure you will, just the fact that you have those goals, you've put that out there in the universe. I'm sure you're heading in the right direction because you've worked yourself to a point, I'm assuming where you're the leader of that ship. You're looking ahead at that goal and people have followed in line with you and you've got the right people in place to do that. You've established a great foundation if you have six clinics.

I would be the first guy to say this. Back in the day when it was my wife, I and somebody helping us getting started, a PT technician or a PT aid, my goal was to see as many patients as I possibly can and attend to twelve-hour span on a daily basis. I thought that meetings were foolish. I thought it was a waste of time and that there was nothing productive that came out of meetings because you're not seeing patients and not being profitable. Little did I know that fast forward to the present day, I do more meetings. Each of those meetings has such significance and consequence to make sure that you have proper systems in place, proper structure. The best and most appropriate people for each position doing what they do in what they're good at and ways to oversee those and have the proper metrics to track those things. Most importantly, I believe we're developing a brand and a culture with what we're doing, which is what excites me and makes me love getting up every day and come to work.

That gets exciting when you get to that point. I'm sure you've recognized that you are the leader, you are the CEO, you have the vision and you're also the executive in terms of managing metrics and establishing systems and policies. In those meetings that you're having with people, you're also a coach. You're there to essentially serve your team members and you're coaching them and training them on what you've learned along the way.

I like to believe that I'm coaching them, but I learned a long time ago from somebody much smarter than me is that you don't have to be the smartest person in the room. If you surround yourself with smart people, that is definitely going to carry a lot of weight and carry over. I believe in many instances, I have a lot of the answers that people are looking for or that we are looking for. I've also learned that now going from two people in a business, being my wife and I to 25 plus, that the most important thing you can have is a voice from every one of your team members and let them know that their voice is heard. It's important that everything that they have to say could mean the difference between making a positive versus a catastrophic decision and I think that it's of critical significance. I learned a long time ago that twenty heads are better than one for sure.

It's so nice when you have a team that has strengths that complement to you. People can do things better than you do and sometimes they've got more energy than you do towards certain goals. It's nice when you can have that complement of teammates.

I'm a big fan of the SWOT analysis. When you find someone's strengths, we all want to feed off that strength and enhance our weaknesses with someone else's strengths. When we're strong, share that opportunity for them to improve and for them to strengthen whatever weak points they have as well.

You are the AR guy, the real estate acquisitions guy of Next Level Physical Therapy and you wouldn't get to the point of six locations and managing that well if you didn't have a solid foundation of financial understanding. That's what we want to get into a little bit more and your thoughts on how to establish and achieve the financial goals that you have as a PT owner. We have these altruistic ideas that we want to become the premier physical therapy clinics in our location. We want to serve the community, but that doesn't happen unless we are able to profit, if we're not able to be sustainable financially. Talk to me a little bit about your thoughts regarding that, how to establish and achieve financial goals.

PTO 71 | Achieving Financial Goals
Rich Dad Poor Dad

You hit one of the keywords, Nathan, right off the bat is profit. In Next Level PT, when we are talking with other owners or private practice owners, many times people will be saying, "I made $1 million. I made $2 million. I made $500,000 but I still don't have a lot of money. I don't know where it all goes.” How many times have you heard that? I'm making a lot of money but I'm spending a lot of money. We all know that it outlines everything. Profit is the key term the way I look at it. In particular net profit, but profitability and a percentage of profitability that you have in your clinic is what is the key. You can make $1 million in a year, but if you spend $900,000, you're 10% profitable. However, if you can make $1 million and you made $200,000, you're a 20% profitable company. That obviously not only helps you, it helps your staff with those people that you might be relying on bonuses and extra payments.

It helps you with expansion purposes and grow that helps you buy equipment that might be necessary. For a guy like me who loves real estate as a passion and as a secondary thing to what I do with my physical therapy. Physical therapy has afforded me the opportunity to also get significantly involved in real estate acquisitions, both from a commercial and a residential standpoint. As a secondary means of not only income but as investments and building equity. For me, it's like a future retirement thing.

To go back a little bit, we talked about profits. What are you saying based on your experience or maybe what do you hear within the PT industry that is either a minimum level of net profit that we should expect out of our PT clinics or maybe if you have an idea of the industry average, what do you know about that?

From research and from talking with a lot of the other cofounders with Next Level PT and interviewing a lot of physical therapy practices and about their profits. It seems like the numbers are magic numbers that you're hearing is that, "If you could be 10% to 15% profitable, you're doing okay. You're doing pretty well." You could be 15%, 20% profitable. You're probably in the top 20% to 10%. If you could be in above 20%, 25% or more in terms of profitability, you're probably in the 3% to 1% for profitability in terms of overall looking at physical therapy as a whole.

I think we're on the same page because I'm assuming that the average net profits are somewhere around the 15% range, maybe a little bit less. If you're doing anything less than 10% net profits, that's tough to justify being an owner of a company that has less than 10% net profit margin. Those guys that are doing over 20% are killing it. A lot of that can depend on location and the reimbursement rates that you're getting in your clinics. That sounds about right.

Nathan, you hit some key components in there as well. A lot of that can be contingent upon the certain metrics that you look at, whether it's reimbursement, whether it's the caseload that you carry. There might be somebody with 50% Medicare versus somebody who has 50% worker's compensation. Where we're at, the worker's compensation is a much higher payer for what we see comparatively speaking to some other insurances. We'll have the insurance companies that might reimburse you only at $60 a pop or $55 a pop, but then you have some of the higher reimbursing ones depending on your charges, which is a hugely key component that we educate our staff on and talk about regularly is proper billing and charging. I don't know how you feel about this, Nathan, but notoriously as physical therapists, we undercharge and underbid, “We're afraid to charge that." Why? You did the service. What are you afraid of? You documented, you have proof, there's nothing to argue about there. Those things and having those metrics in place can set the foundation and tracking those metrics to make sure that you're being as profitable and maximizing your revenues as best as you possibly can. It’s a key.

I want to get to those exact metrics that you recommend that people follow. PTs in general, I like to call us compassionate billers. There's so much fear in our industry already. We fear that we're going to overbill or we want to be generous or we think somehow we will be looked upon more favorably if we don't charge everything that we did. I don't understand it. If it's unethical to overbill, I think it's also unethical to under bill because we should be getting paid for what we provided. It's up to us to document and justify it. You know it and I rail on it a lot. Nonetheless, what are some of those key financial metrics that you might recommend every PT on or be following? 

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There's a couple of that. For each person, it might be a little different. For me and for a lot of the founders in Next Level, we clearly look at patient visits as a big one. You could look at that, but if you're getting $60 a patient visit versus the $80 a patient visit, there's a huge difference. The next thing is charges per visit is what we touched upon. How much are you charging per visit? More importantly, based on those charges that you're doing per visit, how many of them through the EMR that we like to utilize? There's a direct versus indirect units. Being direct is getting better reimbursement. That might be your therapeutic exercise, your neuro reeducation, your therapeutic activity and your manual codes. It’s much more handsomely than an ultrasound or a cold pack. That's a key component that you want to look for. In addition to that, we look at our initial evals. Is that an important one to track? How many units are being charged on an initial eval? Nathan, why do you think that's super important?

Because you can charge on top of that initial eval and you should be if you're doing any work outside of the assessment itself.

You're absolutely right. What does the eval do for every visit they're to follow? It sets the foundation. If somebody is coming in, why do 90% of people come to physical therapy or more?

They're in pain.

If you're coming in and I'm having this range of motion, this manual muscle test and these special tests and you're like, "You're hurting me," and then I do nothing and you leave after that, there's a great likelihood that person might not come back. They’ll think we're masochists and we're not really there to help them. It's critically important to get the proper treatment and charge capture on that first visit to set the tone in the foundation for what people are doing there. That's a key component. Schedule efficiency and clinical efficiency. These are a couple of other ones that you want to definitely look at. You should know in your practice how many times per week your patients are being scheduled. We like to look at a 2.3 average across the board. That means if you have 100 patients on a plan of care, you should be at about 230 visits for the week at 2.3. Sometimes people look at these numbers and all of a sudden they're like, "I only have 165 visits scheduled." That means your schedule efficiency is at 1.65. "No, we know our patients two to three times a week." I understand what you're telling your patients, but your front desk or someone else is not doing that or the patients are not adhering to that.

That’s a big issue because right there, I made some adjustments to how I was billing. We discussed about how we under bill a lot of times. Also, I'm sure you're familiar with redundant coding. If you charge a Medicare patient, for example, three therapeutics exercises over 45 minutes span, the second and third units are going to be reduced in terms of the amount of reimbursement compared to the first. If those units could be more wisely utilized or built accordingly for a therapeutic activity or a neuro reeducation task, you are automatically generating $4 to $5 to $10 to $15 more on that session for those little tweaks and changes, which I think is immensely important.

It's huge if you consider maybe if an average reimbursement per visit was $100. For some people, that's pie in the sky. If the average reimbursement was $100 and you were able to increase your per visit charge by $10, it's $10, but then at the end of the year, that's a 10% increase.

PTO 71 | Achieving Financial Goals
Tax-Free Wealth

To the readers, I would assume that anyone of us would take a 10% raise as quickly as possible. I think that's tremendously important.

To comment on some of your other key performance indicators that you're addressing, knowing that reimbursement per visit is huge simply because some of those contracts are $50 per visit, $60 per visit especially as these third party administrators come on board. We need to know exactly where we are at on the reimbursement per visit side so that we can appropriately say yes and no to some of these contracts. It's in our nature to simply take all comers but we don't necessarily look at how that affects us financially.

I couldn't agree more. We typically do not participate with tertiary insurance parties. We have had numerous ones in our area giving examples. For workers' compensation, there are several that will pay $90 to $100 on the eval and some will pay $70 and some will pay $85 on the subsequent visits. For some people reading this, they might be like, "That's great." They might only make, and I say only because that's maybe designated for their area, $65 to $70 a visit. They might say, "That's crazy not to take that." When you consider not doing that and they can still be referred to you, we can easily make on some of those insurance carriers $125 to $150. That's night and day differences in terms of that reimbursement. That's a huge key component. Knowing another metric is knowing your percentage of patient caseload. For people out there who may take a medical assistant space plans, maybe traditional Blue Cross versus Medicare versus workers’ comp and automobile insurance. If you ever practice that 70% of workers’ comp like in my case versus a practice, same case that's 70% medical assistance, you're talking $65 a visit versus possibly $130. You doubled your reimbursement times 70%. I'm sure you can see the difference that can tremendously make.

Knowing that payer mix can be huge because number one, knowing what it is and then number two, knowing if that's what you actually want to see can really affect at that point of marketing strategies. We need to steer away from some of the more medical assisted plans, whether that's Medicare and the workers' compensation field more. You can start establishing some goals and some metrics to see that payer mix change and get some of those higher payers coming into your clinic.

One of my colleagues, we often say when we have discussions is no metrics, no conversation. If you can give me the metrics on what your patient population is or you give me the old, "It might be about 30% to 55% Blue Cross. My units per visitor are between 3.7 and 4.6.” I could say 4.5 to 4.6, but anything more than that, we really need to get down and dirty knowing the metrics, knowing your numbers. Statistically, you could make a proper educated decision financially on what's in your best interest on the decisions to make. Let's face it, this is how people can expand clinics, how they can grow things. For people like myself who have six clinics, it's important to diversify how each clinic separately is doing. The Next Level PT, we do a clinical analysis form for each of the clinics to see how profitable they're being, what type of volume they're seeing, when is it ready for growth? When do we need to let somebody go? You can tell when a clinic is growing or static, you can tell when it's hemorrhaging and knowing those numbers is of immense importance.

You have a separate QuickBooks account for each clinic and you're also tracking metrics separately per clinic?

The metrics I do on my own. One of my best friends at my clinic is my accountant who does the QuickBooks for me. Your accountant could be your friend or your foe and I mean that wholeheartedly. It's like anything else. If you added a therapist that was doing 80 visits a week and just crushing it every day and yet another therapist is doing 40 visits or 45, you'd be like, "What's going on here?" Somebody who's clearly subpar and maybe not doing what they could do. It’s the same thing with your accountant. Your accountant is one of the utmost importance on your financial team to help you and educate you in making proper decisions about the health and viability of your business. For me, my accountant keeps track of my QuickBooks and then shares that with me whenever I want. We make it a point that we meet every month without question or sooner if I want to go over the various details of how things are going. In between those, every week I have metrics that I'm tracking and looking at through my in-house billing and looking at from those perspectives, many of the metrics that we talked about to see that we are on point of doing the things that we should do.

The most important thing you can have is a voice from every one of your team members and letting them know that their voice is heard. Click To Tweet

I recognized in my experience and I love that you're meeting with your CPA monthly and I recommend the same thing to everybody. I noticed a difference in my financials once I did that. My CPA would simply check in once in a while, maybe once a quarter, every six months or something like that. Finally, I told him, "I need to meet with you monthly. I need you to show me what a profit and loss statement looks like and what it says and how to read it myself without talking to you. I also need to know what a balance sheet looks like." It's when I started gaining control over that information that I had a little bit more power and I saw a difference. I started seeing a change in my company because I was looking at financials on a regular basis.

Looking at your cashflow statement, your balance sheet, your profit and loss, those three, if you're reading this and you are unfamiliar with those terms, you want to definitely be reviewing those on a minimum quarterly, preferably more frequent than that. These are things I recover with my account on a monthly basis to make sure of the health and validity of our business that it is sustainable. That we are growing and we're not going backward in addition to what we do on a weekly basis to track these things.

You have to do this with six separate clinics, but if you had one clinic, you need to know your breakeven number. It’s like, “How much money do I need to make in order to make a profit?” Do some reverse mathematics to figure out how many visits that is. If you don't know that number and you're in a cashflow crunch, you're in a hard time so you need to know your numbers and what it takes to get to that profit margin that you want.

Everybody always likes a good story and my story was years ago, we decided to go into the electronic instead of paper. We are glad we did that. I'm very happy with what we're doing with that. When we made that transition and switched up the billing companies that we were utilizing for that to do the interlink between our EMR and then the billing that goes out. There was an issue with that transition, and believe it or not, my practice was 38%, almost Medicare based and for over 4 to 4.5 months, we had zero reimbursements for Medicare.

Imagine operating your business at 62%. Nothing changes except your revenue. The good thing is I knew I was going to get that money. The bad thing is I had to wait four and a half months. That's why we talk a lot about in our own business as well as Next Level. At a minimum, you want to try to strive for a minimum of two, hopefully, three times cash reserves of what your monthly expenses are to cover something like that. In other instances, most people would probably potentially go under or try to find other means to support them to get through that.

You can't do that unless you're free like you are to look at the metrics and look ahead. I could say that having gone through a couple of EMRs that if you're going to switch EMRs, you give some sage advice in that. You want to have a nice cash reserve set aside because it's not smooth sailing no matter what the EMR companies tell you. There are going to be some hiccups. How long did it take for things to really clear up for you guys? Is it about six months or more?

It was about this time years ago when we did the switch. It went all of October, all of November, all of December, all of January into the first two weeks of February when we finally started getting reimbursed. Thankfully we were getting larger lump sums coming back that was catching us in arrears and getting us caught up. Thank God that we did have 3.5-ish to 4 months’ worth of reserves to carry us through that. I was ready to crack open my piggy bank when it got to that point after so long.

PTO 71 | Achieving Financial Goals
Achieving Financial Goals: Your accountant is very important on your financial team to help and educate you in making proper decisions about the health and viability of your business.

 

It’s good information to share. Yours is a real-life example. Switching EMRs is not an easy thing and it can take a lot of toll on the clinicians. It can be a big toll on your cashflow if you're not properly prepared for it like you're about and try to smooth things out as much as possible on the front end. You’ve got to expect about a six-month time frame.

Three might be adequate, but I think you nailed it, six months is probably safe.

I love talking about the statistics that you brought up, especially the charges per visit and the average patient visits per week. The number of time a patient comes in per week on average. It goes back to number one, if you can improve those stats, it improves your financials. Also, if you improve the average number of visits a patient comes in per week, your results are going to be better because your patients are going to get better. We don't typically measure that and it's not easy for a lot of our EMRs to track that. I don't know about you but I think most people I have come up against, have to do it manually and that's okay.

The other key component that I failed to mention too, that goes right along with the patient visits and a frequency is the length of stay is tremendous. You may look at it and some people might say, "I have a length of stay of nine, so I get people better in nine visits.” That's fantastic. Some of those people though that aren't fully better, even though they met their goals, can you reestablish goals? Can you reestablish new expectations for that person to push them further? It's like a professional athlete. They throw 95 miles an hour pitch, they want to throw 98. Can you get them to that three miles an hour? For some people, three miles an hour, three extra visits on somebody who sees 1,000 new patients a year at ten visits, you'd take that and you go, a length of stay of thirteen, you can't imagine what that small. Do you know how they talk about the power of compounding interest? The power of compounding length of stay for patients is absolutely tremendous. I'm not sure what the literature that you've seen, but historically what I've seen on average of people who have some of the best outcomes and best results come somewhere between seventeen and eighteen or more sessions for physical therapy depending on the diagnosis or the specifics.

The industry average is around eleven, maybe twelve per new patient. I don't know what you've seen, but that's what I saw a number of years ago. We were thought we were doing pretty good with thirteen, but I can see where patients will maybe stop coming if simply their pain has improved. I don't have so much pain anymore. As physical therapists, we know there's more to it than that. There are these people who are going to regress and revert back to where they were before if we don't increase range of motion and strength and that can take a few more visits. That's not only a benefit to them, but it's also a benefit to you, your reputation and your service to the community. It improves your bottom line because many times your expenses are staying the same. If you can tick up and appropriately charge what you should be charging per visit. If you're getting them to come in the number of the frequency that they're supposed to come in, that all hits the bottom line and increases your net profit margin.

If you can ethically, morally and consciously be able to give the patient what they need and perhaps we can extra half a unit out and a visit or two more out of necessity to make that patient reach those goals or exceed those goals that originally established and obtain new goals. Not only is it number one, advantageous and beneficial to the patient because you're going above and beyond exceeding that patient's needs or original expectations, which who wouldn't love that. Secondly, for your bottom line, it has a tremendous impact on that.

Not to divert the conversation too much, there's constantly a conversation about whether you should own your space versus lease your space and the benefits of both. Give us a little bit of that as we're getting to the end of our show.

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I love physical therapy. It's a passion for sure. I have come to love real estate as much probably at this point in time in my life as like with many things. I'm sure you have physical therapy, the people who mentored you for that and possibly steered you into this field. It’s the same thing with real estate. I had some people locally and meeting a lot of different people who deal with real estate and some names that people would really recognize and some that would never recognize. It steered me towards the value and benefit of real estate. I have a lot of owners ask me, including founders in NLPT, as well as other owners that we have in the group the benefits, the pros and cons to owning versus leasing. Some are very obvious. If you lease, you'd turn the lights on when you come in and you shut the lights off when you go home. If the toilet is leaking, if the lights burn out, if there's some leak, if something’s not working, an electrical outlet, you call the landlord and say, "Get down here and fix these things. They're not working," which is fine and he has to fix those. Depending on the lease and the setup you have, which is very key. I have many owners that will connect with me questions about their lease, about their rental set up and about the terms of the lease.

I'm not a lawyer and I tell them that, but I've seen enough leases and I've gotten enough leases working with my financial and real estate team to know maybe some of the key components to look for. As opposed to owning, for me, it's been a Godsend with owning. I own four out of the six clinics that I have. Probably there will be one more. That'll be a fifth by 2020, five out of six. I'm always looking to do that. Owner operator, for me, has been advantageous in all of the commercial real estates that I do have because I also have some residential. I am an owner-operator, but I also have tenants. The ultimate goal with being a landlord for myself as well as for other people is trying to develop ways and strategies to utilize real estate to help out in my physical therapy business and vice versa. I look at real estate as a long-term investment. Some people can get someplace and flip it. You heard a flipping, they’ll flip it and make a quick $5,000, $10,000, $100,000, you never know. For me, I look at it as long-term investments and the advantages for me of owning exceed definitely the advantages of leasing.

I think you can see because you're developing this portfolio of real estate that you're setting yourself well for retirement and the passive income that comes with owning the real estate after you're done with physical therapy and it sets you up to be in a position of wealth. You can have equity in something, you can have that passive income and you also get certain tax advantages that you don't get if you're leasing.

That's most people's least favorite word, tax. For me, I'm not too crazy about it either, but the tax advantages with real estate, like in leasing, you can also write off the lease payments. I'm sure that's something that you discuss with your accountants. For me, it's imperative to have an accountant, to have a financial advisor, to have a wealth expert and to have a lawyer familiar with real estate type of stuff or business lawyer, for your physical therapy practice. Those components are super key to have on your team, especially if you're involved with real estate or even physical therapy in general.

You need to have people that you can count on to know every aspect of the financial and legal world because you don't have that knowledge.

Absolutely not. I'm a physical therapist. I'm not a real estate guy per se but I'm learning the tricks. I'm learning the trades. I've owned real estate for about eight years and I've learned about something called cost segregation. Have you ever heard that term before?

Yes, I've heard it but I couldn't define it for you.

PTO 71 | Achieving Financial Goals
Achieving Financial Goals: It’s advantageous and beneficial to the patient when you go above and beyond exceeding the patient's needs or original expectations.

 

You know how with some properties you have depreciation and amortization. Let's say you have a $390,000 building, you could take that and depreciate that over 39 years traditionally, which would be $10,000 a year. There's something called cost segregation where you can pay this company. I deal with the one in particular out of Florida, but you pay this company and they do a cost segregation study on your property. What they do is they can expedite or speed up the way you can depreciate some of that property. They amateurize it into 5, 7, 15 and 39-year properties. Even though you look at a building, the whole building might be 39 years appreciable, but certain components of that can actually be depreciated much quicker. That's a great way for people that are looking for advantages on tax savings and ways to decrease potential your tax burden through real estate cost segregation. It has been a lifesaver for us utilizing that component of real estate to help. Just that one single advantage has been tremendous.

If you didn't have that input from a professional, you could lose out on tens if not hundreds of thousands of dollars in tax savings.

That takes us back to my accountant that I discussed with cost segregation for tax savings. My original guy said, "We don't get involved with that. We don't do that." That's like saying to your patient, "We're a back pain clinic. We don't do much of rotator cuffs, even though I was trained in school to do that." It doesn't mean you can't help me with it, you're choosing not to. That was one of the reasons that I decided to make a switch and go with a different accountant that was better able to suit my needs and suit my wants of what I was looking to do. For me, it was clearly a blessing in disguise in making that transition. I can't reiterate the importance enough of that financial team and your biller, depending on who's on your billing team for physical therapists is an extreme key component to that. The biller that I have here, I wouldn't trade her for $10 million for sure.

Once I found that right biller in our company, that was a saving grace and it was the rock of our company. Everything else could fall to crap, but we knew that our biller was going to be awesome and we loved her. Katie was amazing and she still is amazing. Having the right biller is huge.

That goes back to some of the key metrics that we're talking about as well is that's the right person. They have the key things in place that they see certain things that are coming through. They don't put the charts in because that's their job. They see the changes that are happening. They are someone who's going to reach out to insurance companies every six months or once a year and be like, "Is there a possibility we could renegotiate and possibly up our reimbursement $1 or $0.50?” That goes a long way with hundreds and thousands of visits.

The thing I loved about Katie is, we met with her so often, at least by the month, but she was providing us reports weekly. She would give us red flags as to what might be happening at the front desk. "We're noticing that a lot of these things aren't getting authorized or we're noticing that we're getting incorrect information on the insurance verifications and whatnot." They can give you a heads up if you have the proper communication channels in place about what's going on the backend of your clinic.

That's why meetings with all the different departments, we like to look at things from an organizational chart or organizational board perspective. If that works from the top down, but when you look at an org board it branches out like branches on a tree. Everything has to be connected to that trunk concentrically so that everyone knows that everyone is on the same page. If one person might be missing something, we have some other way to check and balance that off to cover that and make sure that we're covering all of our bases.

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Frank, can I ask you what EMR you guys are using?

We're using WebPT and we linked that with Kareo as our billing software.

You guys have been pretty happy?

I have been, yes. I don't know if you recall this one from way back when, but we use PTOS.

I never used that one.

Physical Therapy Operating System and that was something that we utilize way back when. It served us very well, but that got absorbed and WebPT was one of the ones that came to the front of the line for us and we looked into several different options. For us and for our staff, it was a nice learning curve and a good transition for us that worked out well. It makes the billing process pretty streamlined, which is great.

It's good to know what you're using because we talked about a lot of key metrics that you have to track and follow. You want your EMR to provide as much of that as possible without having to do the manual labor. You've been relatively happy then with the reports they provide.

PTO 71 | Achieving Financial Goals
Achieving Financial Goals: It’s important to have meetings with all the different departments so you can look at things from an organizational board perspective.

 

We do utilize as well as a form. We've created several forms internally in Next Level PT that we utilize almost pretty much daily or weekly and monthly. To WebPT, I love utilizing their analytics that I can pop up and see metrically where we stand with some of these statistics to be certain that we're doing all the right things that we should be. How we can be strong and where we're strong, how we can improve?

Are you able to get off of WebPT the frequency of patient visits per week or is that something you have to track manually?

We have an active patient tracker that we utilize for that. That is one of the products of Next Level PT that one of the other founders Chuck Schulte had worked on. That is something that all of us are utilizing. It's like a godsend because you can track how many times a week they're scheduled? How many times a week they should be scheduled? How many times they actually came in? We all know that there's a lot of variation in that.

That's my challenge to all the EMR companies out there is that should be a key component of the metrics that they provide. Maybe they need to talk to Schulte and you guys might have a play to get bought out there. Frank, anything else you want to share with us here?

Nathan, I want to thank you for having me here and sharing some information. I hope that if anything, whether somebody could take one thing out of this or ten and someone finds it advantageous. If anyone needs to get ahold of me, they can feel free to reach out to me anytime at CawleyPTFrank@Gmail.com, or feel free to check out my website CawleyPT.net. You can reach us through Next Level PT on Facebook or you can reach me at Frank.Cawley@NLPTBaseCamp.com.

If anyone out there hasn't been on their Facebook group page, I highly recommend that. You guys have some great information to share at the Next Level PT BaseCamp.

Thank you, Nathan. We have a great team. There are nine founders. All of us have our strengths and all of us have our weaknesses, but that's the beauty part of that. Where I might be sitting here by myself trying to figure out a solution to something, I send out a text message to eight other guys at least probably two to three are like, "I do that. I got you. Here you go," which is great.

It's the beauty and it's the evidence of the power of networking.

There is no doubt.

Frank, I appreciate your time. Thank you for coming on.

Nathan, thank you so much for having me. You have a great thing going on. I love your show.

Thank you, Frank.

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About Frank Cawley

PTO 71 | Achieving Financial GoalsFrank Cawley was born and raised in Pittston, PA just 2 hours north of Philly and 2 hrs south of NYC! Fun fact...In the 1970’s Pittston PA was home to the 3rd leading Mafia city in the country! Frank is the youngest of 3 children (Katie and Colleen) older sisters. Frank’s dad was in law enforcement his entire career and his mom was an administrative assistant. Frank and his sisters were the 1st generations of Cawley’s to go to college. (Thx mom and dad for guiding us and never letting us settle for average or mediocrity)!

Frank was denied entry into PT school his 1st two times he applied. On his third go-round, he got waitlisted and was accepted 2 days prior to classes starting and was informed there were no more dorm rooms left so he would need to find a place to live over the next 48hrs!

Frank opened his PT clinic (only through the support and guidance of his wife of 16+ years Courtney). The day we opened (April 3, 2003) we had a grand total of Zero Zip Nada 0 patients on the books! Fast forward to 2018, we currently have 6 locations seeing over 600+ visits per week and are working on opening more offices (and a gym by 10/2019)!

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In this episode, host Nathan Shield talks about the people within your company with the CEO of Pure Physical Therapy and Founder of Next Level Physical Therapy, Frank Garza, PT. Frank started seeing growth in his PT clinic once he started weeding out the "bad apples" in his organization and focused on hiring and firing those people who weren't in alignment. How did he do it? He, along with his wife, established the purpose and values of the company and hired and fired accordingly. Now, the people on his team are rowing in the same direction and growth has accelerated. Plus, the energy in his clinic is fresh and exciting, and the culture is drastically changed. Want to establish a culture like Frank? Set the standards, establish purpose and values, and get your team on the same page. Your growth and an exciting culture will immediately follow!

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Listen to the podcast here:

Identifying The Bad Apples In Your Organization With Frank Garza, PT

I have Frank Garza out of Texas, a successful physical therapy owner who recognized that once he had established his purpose and values, he was able to weed out those employees that weren't on the team and we're limiting him. By removing those people, he has been able to achieve significant growth. Based on the book, Tribal Leadership, Frank recognized that there were certain stages of people and certain stages of a team that contribute to your success. As you weed out those people that are in stages one and two, and as you move your team into stages four and five, that's when you make significant growth. That's when you make significant progress and start to achieve the purpose that you set out to achieve. This is great that we can have a personal experience establishing the purpose and vision, hiring accordingly, getting the right people on the team, and then seeing the success that comes from it.

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I've got Frank Garza, a physical therapist out of McAllen, Texas. He is the CEO of Pure Physical Therapy and Pilates and also a Founder of Next Level Physical Therapy mastermind and consulting group. I've interviewed a number of original founders and members of Next Level Physical Therapy. Frank is on to talk about an important topic. Thanks for being with us, Frank. I appreciate it.

Thank you for having me, Nathan. I appreciate it as an NLPT being able to come aboard and talk about all the stuff that us private practice owners wish we knew when we were starting.

Tell us a little bit about you. Where did you start? Tell us about your physical therapy path and especially your ownership and entrepreneurship path and what's led to where you are.

I graduated and I played sports. I think like most physical therapists, they get into it because they got hurt and got exposed to the field and connected with their physical therapy team at the time. That's how I got intrigued about it. I ended up graduating and I coached and taught for a little bit. I liked that, but I knew that I wanted to be my own boss. I knew that I wanted to do something that I could control and that I could lead. In football, that's the position that I held. I liked it and embraced it. Going into physical therapy, I knew that I could have my own business. That's why I got into it too. I went through it and got out. I worked for a private practice clinic for a year. Right after that, I felt I knew enough to go out on my own and do things on my own and get my feet wet. I say sometimes that I rushed it and I say that might have been a mistake, but at the same time it probably could have been the best thing I did because people were there trying to help.

There was a time when there was a lot of work. Private home health companies were picking up PT companies to do their home health visits on the side and paying them a good rate. That's how we got started. We said, “This is an opportunity to go on our own and do something that we can fill our schedules and get other people to work under us.” We did that model for two to three years and then it went south bad. Luckily, we had already planned to do our outpatient clinic and that's how our outpatient clinic got started.

You started doing home health first before you went into it.

We started doing home health first. The reason for that was the people that we were working for said, "There's enough work out there. We'll help you get started.” You build your company name, you get a contract, you start bidding home health agencies for work. There was so much work that you could fill your schedule fairly quickly. It's also something easy to manage. You didn't have all the red tape about credentialing and audits and all that stuff with paperwork because they controlled everything. You were just a contract payer. It was a good way to get that taste of freedom, flexibility and ownership of your own business. At the same time, it was one of those models that you were chasing the profits all the time. You weren't making that much money and you were seeing a lot of patients, you had people that were underneath you seeing a lot of patients and you have to pay them. If they didn't pay you on time, then you couldn't pay them on time. We started learning that it wasn't a great model to grow, to scale and to make the money that we wanted to make. We started saying, "Our ultimate dream was to have an outpatient clinic." We had enough capital to invest in that.

It’s a good thing we did because the home health went south shortly after that. There were a lot of people getting busted for fraud. That model went to hell. We've entered into outpatient and we did what we did and we got started with what we knew. The experience of running the home health, but it was a totally different monster. There were so much things that we had to do before we even saw our first client, our billing and all this other stuff. It was an adventure, to say the least. We knew right away that we needed to hire people to help us. We hired staff. We chugged along for a year, two and three. Have you ever been on a roller coaster ride and sometimes the whole cart shakes on one of the stable tracks? That's how the first three years felt like.

You almost have to fail at everything HR before you understand it. Click To Tweet

Not everybody was a good fit for your team, I'm sure.

That's exactly what I was going to get to. We started realizing quickly that who we hired was like, "It's not going to work out. Who are we going to hire? We don't have anybody to hire." I think our mentality at the time was, “We need people to work for us. Let's pick up whoever is available.”

“If they're breathing and can follow some instructions, then bring them on.”

If it was somebody that somebody referred, that helped. That's even better. There were people that we knew in the home health field and they were like, "I have a cousin, a friend that was looking for a job." We quickly assemble the staff. We also quickly found out that we were in for some trouble if we didn't fix it because it wasn't the ideal staff. We didn't know what the ideal staff was. We learned a lot.

In my situation, I was like, "I don't necessarily have any job descriptions written out, but I'm going to put you in this position. I expect you to do what you're supposed to do." I was so naive to think that I could put him in a position and expect immediate productivity, an immediate buy-in. I found out later on that it was probably good to hire people who have bought into your vision, who share the same values. They're aligned. Maybe it's even better if I actually develop a job description and tell them what productivity looks like and how I'm going to measure them. It all comes over time, but you wish you would learn that sooner rather than later because things change when you start hiring based on that model.

I learned a ton. I learned that if we had concentrated on that department itself early on, on the human resource department for sure, that maybe we have not struggled as much as we did because it was a struggle. I look at my position and I'm learning that it's still a continuous work in progress. There's never HR and building your culture and your team like that. That doesn't stop because it's always evolving, things happen within your team and you’ve got to replace them. There are some things you can't control, but it's a work in progress. I also learned that you almost have to fail at everything HR before you understand it. We're not taught any of this in school. We don't know where to grab all these concepts, stuff and resources early on. It sometimes takes you telling the story of failure to another friend and they're like, "You had to do this and you’ve got to read this. You should go take this class." You learn a lot from failure, but who doesn't? One of the other things that I learned is that you cannot swipe someone else's HR material and expect for you to understand it and then much less for your staff to understand it. It doesn’t happen.

You think that there's a one-size-fits-all HR employee handbook. That's not true. Much of your culture and so much of you is simply how you do things. That's what I consider culture to be. This is the way we do things around blankety-blank physical therapy. That eventually develops your culture and it goes even back to your HR material. This is how we treat patients. This is how we expect you to show up to work. This is how we handle disciplinary actions. All that stuff needs to be broken down and individualized for your own clinic.

The number one thing that I learned early on is that we did not have that company culture that we wanted for the first three years and we have to fix it quick. It started with us, which is exactly what you were saying. We have to make a transformation mentally of what we wanted to instill in our company, what the vision was, what the mission was, how were we going to do it and make sure that everybody understood that, everybody was clear on that message. That was the number one thing that I think if people are out there wondering, "How do I do that? How do I avoid making the same mistakes?" Travis already did a show about this. It starts with us and our vision and our mission. It’s making sure that our staff clearly understands that and making sure that everything they do is working towards that common team goal that you're trying to accomplish. It's something that we realize we didn't have early and we started to change it quick.

It's probably you and your wife that came up with the vision and the mission. Maybe you created values between yourselves and your team. When you finally implemented that after three years, was that rough to implement it and get everybody's buy-in? Did you end up getting rid of a lot of people after establishing and planting the flag like “This is who we are?” Was it an easy transition for you or was that something that got smoothly brought into your company?

PTO 70 | Identifying Bad Apples
Tribal Leadership Revised Edition: Leveraging Natural Groups to Build a Thriving Organization

The transition is never easy when you're trying to get rid of bad culture and create a totally new culture. For us, we identified that we had people already in our organization that we're not going to work out based on the meeting that we had about our mission and vision, all that stuff about what kind of individuals we wanted, what kind of characteristics they needed to have per each individual position? That's key too because you want them in the right position. All of that starts with us. We need to identify the vision and mission and how you are going to do it? It’s on your core values. If you know that you're hiring for the front desk, you're going to go look for certain characteristics for that front desk. That's your expectation. You got to give them an expectation for every position. I looked back and I said, "What did I do in some of my coaching career with my team to get buy-in and culture? What did other coaches do with me when I was playing?” There was one coach that brought out a binder like it’s the beginning of the football season and everything that we were going to live by that season was in that binder.

Our hyped-up a chant before the game is spelled out, everything is written. That was his way of instilling that culture. It was a new coach coming in. He was changing everything. Even before school started, we were reading stuff through that binder and getting to know what his philosophy was, how we were going to do things, and how he expected us to do things. If we didn't abide by-in or if we're doing something different, then there was a consequence to it. The same thing applies to your business. You got to set that standard as a CEO and as a leader. You make sure that they follow it.

That's the important thing to note. A lot of times when you set the mission, vision and values in midstream that you've been practicing for a few years, you decide, "Let's establish a foundation and get down to some fundamentals and talk about vision, mission, and values." Inevitably there are going to be some people who don't like the implementation of that structure and that don't have buy-in. You're more than likely going to lose some people. You have to understand that up front and you've got to be okay with that because the people that you lose are the people that haven't bought into your clinic. Once you shed yourself from those people and you can attest to this, Frank, you will then experience some accelerated growth. Especially as you start replacing those people with people who actually do buy-in to your mission, vision and values. As long as you're establishing that over and over again, you don't stop talking about the mission, vision and values after the initial introduction. Once you plug it in and then start hiring according to those, then you start getting some people who buy-in and the growth then accelerates.

It’s happened to us on two different occasions. One of the things to educate our audience on is how do I identify the bad ones and the good ones? What are some characteristics of some bad culture in your company? I was brought onto this book called Tribal Leadership. It goes through five different cultural stages. After reading that, I started evaluating my staff and listening and observing their body language. You'll find out right away who's on board and who's not. I'll go through those cultural stages to help people identify them for those that are wondering what are they and how do I identify them. Stage one is characteristics and qualities. This is the type of mindset that creates street gangs. We don't want any of this in our company. Their thing is that life sucks. They're despairingly hostile, they band together to get ahead in a violent world. The great example is The Shawshank Redemption. We don't want to hire stage ones, but sometimes you'll get people in your meetings that have that bad body language and in everything you say they’re like, "No, yeah, whatever." There's always something negative to everything you say. There's always a problem to every solution.

Stage two is a little bit different. Instead of, “Life sucks,” they're a little bit more personal, “My life sucks.” They're a little bit more passively antagonistic. They may not say something verbally, but in a meeting, they'll go cross their hands in judgment and not be totally bought in but not be totally against you either. They never get interested enough to spark any passion. These are the ones that sometimes you come in from a mastermind or conference, you've got all these ideas to share with the group and they're like, "I’m not interested." They're not too excited. By the same token, if you say a funny joke to them, the laughter is a sarcastic resigned thing. They’re the whatever type. The talk is that they've seen it all before and watched it all fail.

A person at this stage two will often try to protect his or her people from the intrusion of management. The mood here is that their life sucks. It’s a cluster of apathetic victims is how they characterize that. Stage one and twos are exactly what you don't want to have. If you're looking and coming into meetings and you're seeing these types of behaviors, you want to know that they're not the ones that you want and then they start changing a little bit. They start getting a little bit more positive. Stage three, the theme is, "I am great and you're not.” Knowledge is power so people hoard it. They're the people at this stage they have to win and winning is personal. They're your big competitor people. They will outwork and outthink their competition on an individual basis. The results from this as a collection of lone warriors. These are your hardworking individuals, but not so much team players. They're often seeking help and support, continually disappointed that others don't have their ambition or skills.

If somebody is not trying as hard as they are, they’ll be disappointed. Their complaint is that they do not have enough time or competent support. They’re like, “I’ve got to do this by myself.” It's a bunch of self-described star players. You can't have too many star players. They can't play together as a team. That's basically the theme there. You’ve got your stage four and five. These are the ones that you want all the time. Instead of going from, "I'm great," the stage four theme is "We're great." This is where I think most of your positive company culture is, your great, thriving, growing companies. When they have great culture, they have a great team. They have a lot of stage four characteristics and qualities because it's all about team. Everyone is excited about seeing each other at work. They take the tribe away from the person's sense of self. These are the people that if they take the team away, they feel like, "Where am I?" They feel lost because they feel the team is their second family. At this stage, the culture is effortless. Nobody's trying too hard. Everybody's doing what they’ve got to do and working for each other as opposed to for themselves.

The only one that has influence is the tribal leader. Here in stage four, whoever's at the very top is the only one that actually has influence over this culture because other than that, there are no lone warriors. Everybody's working together as a team. You have your last one, which is, "Life is great." The language revolves around infinite potential and how the group is going to make history. They want to make a global impact. This is where they make an example of Apple where they say that the innovators from Apple and Steve Jobs were at stage five because they did things that made a global impact and they wanted to make life great. The mood is an innocent wonderment. A very small percentage of companies have this type of characteristic. Most have stage four, but you definitely don't want the ones and twos. That's important to understand, to identify what you have.

That's great because you can put this assessment up against each individual within your team very easily. I think it's easy by what you laid out to say, "Who are my stage one players? Who are my stage two players? Who are my stage threes?" What have you learned? Can any of these people change from two to three or three to four? Do you simply hire slowly or fire fast? Do you simply get rid of them?

The transition is never easy when you're trying to get rid of bad culture and create a totally new culture. Click To Tweet

The ones and twos, there's no change there. The threes can get into fours and that's definitely what you want.

Just cut your losses.

Especially if you have a big organization and you have this person in a position where they have a lot of people under them. If they're a stage one and two, imagine what they're telling all those people under them. Imagine the mindset and the stuff that they're feeding them. That's what those people think of everybody else on top. That's not necessarily true.

When you have those people in your company, they can be a real poison. It's almost like if they're allowed to linger long enough, everyone that they touch in their immediate circle becomes poisonous as well. We've had that experience before in one of our clinics where one person in particular was poisoned and unfortunately, they were the leader. After that person left, it took at least a year before we got everybody out who they had an influence on before that clinic started turning around. Looking back on it, my partner and I both believe that we should have closed down the clinic, fired everybody that had a connection to that poisonous leader and started from scratch and got some new people. It can be that devastating and that pervasive when that one person has that much influence.

I'll tell you a personal story of my own too. Sometimes you think it was so bad and then you’ve got a new staff and it got better. You're meeting some goals that you'd never met before and you're like, "This is great." It plateaued for me. I was like, "What's going on?" We've got a new hire. This new hire, it was the first time we have put them through a rigorous hiring process and had this funnel built out and had all these triggers that they had to do before they even came into an interview. I was like, "This guy has got it." We hired him and sure enough, he came in and in six months outworked everybody in the front desk so much that we redid all our internal processes at the front desk. That's when I knew, I was like, "We may have another problem." That wasn't his job. He was going to come in and do reception. He ended up coming in with all these things and changes and made things better. The problem was those other two people that were there before him didn't I go through that interview process that you went through. We didn't weed out as much as we thought early on.

Since then, we've hired another one and we ended up tweaking his process more to make it more specific and refined to make sure that we got another person just like him. The other two people are not there anymore and the other two that we hired are now all cross-trained the way he did everything at the front desk. When we brought them on board, we made the onboarding process and the interview process very detailed to everything that he had created and changed up there with my direction. Even when you think you've got it, you probably have to do another thing. That's what happened to me. We went through and we hit some numbers that we had never hit the first time around. We plateaued and we weren't hitting our goals that had after that. He came on and totally changed it. We brought these two other girls on.

As soon as the new staff came on board without the old staff here, because there was a little bit of overlap, they have put in their two weeks. There were several part-timers in training. The very first week when all the old staff was gone and it was just a new staff with the person that we trained up there, we hit our 200 visits a week goal that we haven't hit in a while. It always happens for the better, but I feel it only happens for the better if you put in that work, your blood, your sweat and your tears into making it better. We refined our process, we identified the leaks, we identify leaks again. We tweaked and refined the process and we got a better product out of it. You got to keep tweaking and refine. That's the main thing.

That's the perfect example of the theorem that the people that got you here are not the same people that will get you there. Some people will be good at getting you to a certain point. What's cool about this also is it exemplifies how you were so intentional about the person that you want to hire. In your own words, it was a rigorous process. For someone at the front desk, if you can breathe and say hello, usually that's good enough for us to sit at the front desk, but you took it a step further. What do we exactly want out of this person? How are they going to be the most productive and how are they going to be the face of my clinic? Immediately, as soon as you did that and got rid of the other people, your numbers grew again. That’s a great example. 

Our main focus was we want to create overwhelm for these candidates. That's what I told the guy, Bruce, he helps some of my marketing and all my funnels and stuff. I said, "I want to create overwhelm." He goes, "What do you mean by that?" I said, "I want you to give them everything and all descriptions and tasks that they will be having to handle." Even if they only have to do it once, even if it's not their main task. I said, "I want them to feel overwhelmed." I was like, "Why?" It's because if somebody can come in knowing that they're a little overwhelmed and stick the interview, then they're going to be good because there's a lot of overwhelm at the front desk. Wouldn't you agree? He’s like, “Yes.” That’s what our mentality was when we did that.

PTO 70 | Identifying Bad Apples
Identifying Bad Apples: When you have employees that have great culture, then you have a great team.

Congratulations that you experienced that because that front desk is such an important part. Correct me if I'm wrong, are you paying these newer guys a little bit more than you were previously? 

They're still in the probationary period. It’s equal to what it was for the others but going forward, they're both doing verifications. I already prepped them and have their one-month meeting and say, "This is where I want to be able to get you at, but I want to make sure that you're completely independent with all of these things." They're not quite there yet, but they're helping so much more than the other two were as far as what they're going above and beyond doing.

That's awesome because you're incentivizing them and you're telling them, "If you're going to make more, this is how you're going to do it." That's always awesome that you can incentivize them. There was also a change in the quality of the candidate once we decided to increase our per hour rate that we were willing to pay that front desk person. If we were stuck in the $8 to $10 an hour range, we’ve got $8 to $10 an hour type of people. Once we bumped that up to closer to $12 or $15, then we got $12 to $15 an hour people. I'm not saying that you need to share your numbers, but I'm leaving that as an example that sometimes you should be paying a little bit more for someone who is super productive at the front desk because that person drives so much of the success of your clinic.

I had a conversation with my wife about this. We were going to try to increase base pay across the board for techs and front office going forward, but with these expectations, our next tech coming in is not going to start there. He's going, "You're going to start here and you could get to here once you get to a year-and-a-half experience and you're doing this." Our techs had been with us for about a year and a half, two years. They’re in a little bit more responsibility. One of them is responsible for the cleanliness of all the gym and the other one is responsible for all the equipment. We have to order stuff. He knows my online account where we go order. He just gets it approved. They're a big part of what we do here and they're making more, but if somebody that comes in and starts to do tech work, they’re not going to start there. They're going to have the expectation of, "If you can do this like Alex is doing at some point, this is where you could be.” I do bonus them. Everybody got a bonus. We do a little a profit share at the end of the quarter. Even though their base rate is a little lower, when they get incentivized and bonus, it turns out to good hourly grade. I do feel you on that trying to get those candidates.

We're talking about front desk and tax, but this is correlated with physical therapists and PTAs as well, even the clinic directors. They can have such an influence on your team if they're in stage one and stage twos. You want to have more of the stage fours, people that are bought into the culture. We're talking about your hiring process. Are there other things that you do to cultivate that culture and move those people into stage four types of employees where they're bought into the team and it's all about effortless culture or the things you do to maintain that?

I've been working on that a lot. That's something that we've been changing around here because before, we were tied up with life. We're trying to get their business to where it needed to be. Get the kids in the home life to where it needed to be. It wasn't at the top of my focus at the time, nor did I know it needed to be. I started seeing all the positive effects of that. I read a line by Peter Drucker somewhere in his book, he said, "Culture eats strategy for breakfast. It never stops. It's a 24/7 thing." I said that to my wife and I said, "I'm going to take on this hat and know that I'm going to be coming up with some ideas to hang out as a team. We're going to be celebrating any and all little wins, things that nobody else is looking at." We’re trying to create our identity. That's what I told her. As a team, we’ve been hanging out a lot.

Every quarter, we set some goals and when we hit them, we celebrate them. When we celebrate, we go out. I rented a house on the beach and everybody came out and I barbecued all day. They went to the beach and we're in the pool and hung out and had a place to stay and drink. We’re hanging out with each other. We try to create an atmosphere of family and trust just like you do at home. It's hard because it’s like, “They're not your real kids, Frank.” I was like, "I know they're not my real kids, but if we take care of them, it's going to turn around two folds, ten folds for you as a company.” It takes a lot of work.

You're talking about regarding culture, we've talked it about a number of times on the show. When your team members treat their work team as if they were family, that's next-level stuff. You get so excited when they'd not only bought into the company culture, they've bought into each other and they wanted to see each other succeed. They're trying to help and they're trying to promote each other and help each other out. That's the stuff that you hope for as a business owner. In order to cultivate that, it takes celebrating wins, creating goals together. I think quarterly meetings are a huge success. You can push a lot of great cultural values and unity in those cultural events if you're intentional about it and if you plan those out properly. It can gain a lot of traction. It's nice to not only implement the mission, vision and values, but then follow that up with intentional culture-building activities that show the mission, vision and values. We talk about it during those times. That's when you start seeing a culture change.

We try to do that, even when we get together casually, we'll play little games, “Who can recite all our core values the fastest?” We throw stuff out there and always relate stuff to the clinic, even joke about some things that happened in the clinic and create that atmosphere. At the end of the day, we're CEOs and that means we have to lead. We want to lead them to do great things. I used to be a coach too. We can lead them to be good, but when they overachieve and we lead them to overachieve, that makes us feel great. They want to make you feel great. They want you to be proud of them. They don't want you to pat them on the shoulder and say, "Great job." In some cases, you may not know this or they may not tell everybody, but they may have a hard life at home and work is their happy place. It says a lot about how you do that. You can lead by a lot of ways. You can lead by service. You can lead by love. I like to motivate my team. Every Monday, we do a Monday update and we do a little motivational Monday video clip. I'm big into motivating.

Knowledge is power so people hoard it. Click To Tweet

The other thing I've learned that I think helps them respect you and learn a little bit about you as a boss is to not be afraid to feel embarrassed in front of them for something you did. Being in a business where I own it with my wife, I have some experiences sometimes since we work together and we live together. Sometimes you're at work and I may say something that maybe I don't realize that other people are in front and it's rude. When I realize that, I immediately will stop, apologize and make it public like, "I messed up." The faces and the looks that I get from them sometimes it's cool because they're like, "He's normal." They're not afraid of me because they know I'm just human as they are and we all make mistakes. The example is man up about your mistake and make it right or make sure that you expect them to do the same when they messed up. You're going to move on. It's okay.

Show a little bit of humility. Show them that it's okay, that we can make mistakes and we can overcome them and next time I'm going to do better. 

At the end of the day, I tell my kids, “As long as you give it 110%, that's all that matters. Give it your all.”

Is there anything else you want to share, Frank?

This is one thing that I read and I thought I want to share with my staff. I read this and I'm going to share it with them at the next meeting. It says, "If your presence doesn't make an impact, your absence won't make a difference." That goes for all of us. As a CEO, you want to make an impact on your business. You have to come in here full of positive energy, leading your team, motivating your team, loving your team, setting the mission, the vision. Make sure everybody's clear on it so that everybody can focus and go forward. As an employee, you need to do your job and make an impact in your post. When you're not there, it's not going to make a difference.

How do you want to make an impact?

When you're not there, they're going to be like, "Where's Frank?” because you made an impact.

As a leader, you want to be able to say, “I made this impact.” As a leader, especially in a physical therapy clinic, personally I didn't want my impact to be that I saw 60 patients that week. That's not the impact you want as a leader. The impact that you want as leaders is, “I've affected these people's lives whether it's patients and or employees. This is how I lead and this is how I've created a culture that inspires people.” That provides much more power than it does simply treating patients all day.

It's who you are, what are you there to do and how you're going to do it?

PTO 70 | Identifying Bad Apples
Identifying Bad Apples: If your presence doesn't make an impact, your absence won't make a difference.

Frank, thanks for taking the time. I appreciate you sharing your wisdom. If people wanted to reach out to you and ask you questions, what's your contact information? 

I'm going to give you two ways that you can opt in for any information. It's a text message. You can text MM to 844-444-1481. If people want to get onto our app and get some of the free stuff that we have on there for mastermind stuff, they can text app APP to the same number.

That's for the Next Level PT mastermind and coaching that you are doing?

Yes, correct.

It's always awesome talking about culture. I get excited about what we can do to filter out people who aren't bought in and find those people who are bought in because the sailing is so much smoother when you got those people in the right seats in the bus. 

We're still tweaking and refining because that's the process we have for the front desk, but we still got to create one for the clinic and for PT and everything else. It's a work in progress.

Thanks for your time, Frank. I appreciate it. 

No problem, Nathan. Thank you.

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About Dr. Frank Garza

PTO 70 | Identifying Bad ApplesDr. Frank Garza has been a physical therapist since 2006. After working as an employee for one year in private practice, he decided to venture into an independent private practice setting, with his wife, where he is now the CEO.

In doing so they began to see patients in their own home for about 2 to 3 years before expanding into their current outpatient physical therapy facility, Pure PT & Pilates (PPTP), which he owns and operates along with his wife, Dr. Amy Garza.

Together, they have been managing and running the practice for seven years, soon to be eight. Frank is also a founder of Next Level Physical Therapy (NLPT), a consulting group that helps other physical therapy CEOs create the time, choice and financial freedom they deserve.

In the last 2-3 years, he has been really focused on developing and refining his practice’s Human Resources Department. Frank is currently a resident of Mcallen, Texas, a small city located in South Texas, with his twins, Frankie and Tessa, as well as his beautiful wife Amy!

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PTO 55 | Recruiting Physical Therapists

 

Is it easy for you to find a good, qualified physical therapist? If so, this episode isn't for you. Congratulations! For the rest of us, recruiting quality physical therapist is a chore, and not an easy one at that. Will Humphreys, PT has found a way that's been successful for him. Over the years, and now as the VP of Talent Acquisition and Development at Empower PT, he has developed a way of helping physical therapists come into or stay out of our companies. Realizing that not everyone is a fit, his recruiting style is based on being of service to any and all physical therapists. He wants to help them get to their next job, whether that’s with his company or another, and with that mindset and a focus on relationships, he's created a powerful recruiting program that stabilizes his company. The loss of an employee is no longer a significant upheaval but a transition to the next top-qualified candidate. Join us and learn from the recruiting maestro.

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Listen to the podcast here:

The Successful Mindset And Tactics For Recruiting PTs with Will Humphreys, PT

I'm bringing back my good friend and partner, Will Humphreys. I want to bring back Will because he has become a master at recruiting physical therapists. I've had Brian Weidner of Career Tree Networks on and talk about what to do as you're looking for physical therapists. It gets you the general idea of what it looks like and what it takes to find qualified physical therapists. I've also had Dr. Sabrina Starling talk about recruiting or hiring in rural settings. Jamey Schrier talked to me a little bit about hiring A players. Those weren't specific to physical therapists, but Brian Weidner’s was and as will this one be with Will. Hiring for a physical therapist is different than hiring for admin and tech positions. It's a different ballgame and it's harder. At least from our experience in Arizona, it was hard to find qualified physical therapists.

I wanted to bring Will in because during those other interviews, I'd always referenced the success that he had, that we had in finding quality people. He continues to do that at Empower Physical Therapy. The proof is in the pudding. Here's a story that he shares, but I want to really emphasize it and that is he had a physical therapist that put in their two weeks’ notice because they were moving out of state on a Thursday. The very next day, they had a qualified physical therapist. This is someone they've already qualified. They had an offer out to that person on Friday and then on Monday the offer was accepted.

I haven't heard a story like that before when it comes to recruiting physical therapist. That's how powerful it can be when you have a strategic way of recruiting for physical therapists and physical therapy assistants. Will's been able to do that. He shares his mindset. He shares some of the tactics that he used and has come to a point where he has people qualified for at any moment when a physical therapist is leaving. He can put an offer out and have someone in there in a timely fashion without having a significant dip or drop in productivity. I'm really excited to bring him on because I always referenced to his successful action.

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I've got my old partner and friend, still partner and friend Will Humphreys on again. This is the third time so far. You've come on three times. He actually interviewed me, so check that out as well. I wanted to bring Will on because I’ve referenced a lot of what we did at Rise Rehab back in the day for recruiting physical therapists and Will was the headliner of that. He really recruited well for us back in the day and is continuing to do that as the VP of Talent Acquisition at Empower Physical Therapy. He has really grooved in some amazing processes to find quality physical therapist and physical therapist assistants to Empower PT. First of all, thanks for coming on again, Will. I appreciate it.

You're welcome. I'm happy to be here. This is so fun.

Let's talk a little bit about it. For the readers, why don't you tell us a little bit about where we started back in Rise Rehab and how you eventually got into this process of acquiring talents in getting into this groove?

I like that you start that way because I hated recruiting for ten years. As you know, we initially opened a clinic with you as my employer in Florence, Arizona, which is halfway between Phoenix and Tucson. I later learned through some recruiters that I had been working with, they told me that Alaska and Arizona were the two hardest states to recruit based on the number of colleges versus population and all that. It really felt true for me back then because it took me forever to bring someone on. Frankly, if they fogged a mirror, they made it. It’s like, “You're alive and you have a pulse, congratulations,” and you can imagine what culture that created and you're paying more.

I paid one person an exorbitant amount of money to see like 40 visits a week which in Arizona is you're losing money. That was the whole thing. It required me to stay in it. It was a matter of like, “Am I going to make this work? If I do, then I have to figure out this thing called recruiting.” I put a lot of time and energy into figuring it out and it's grown into a passion, even though I hate the word recruiting. I don't think that defines like what I do whatsoever. That's a very bland term. I'm really surprised at how much energy I get from it now and I find myself getting a lot of the same rewards as a talent development and acquisition specialist. That’s the word I'm working with now. I get so much energy from that in comparison to treating patients. It's a very similar energy gain for me. I would never have suspected that as a PT.

Tell us a little bit about your mindset change. You said you used to hate it, but now you love it. What happened there?

It definitely wasn't gradient. It wasn't like an overnight switch in many ways. There was this effort. It forced me to create a culture and you were obviously equal parts in that. We worked hard on creating a culture to where people would want to be there. It includes logistics, things like salary and compensation and having the right benefits. It was more about like making sure who I could hire or hire the best, whether it was a front desk person or a tech. Once we started getting that momentum, we could almost draw people in. Otherwise, I wouldn't have even thought about driving an hour halfway to Tucson and pass a dozen opportunities on the way there. Our culture started getting really great and then we started attracting a couple of really big star people like Michelle Bambenek. You already have Stacey Sullivan. These rock star individuals brought so much personality to the company. It was like a snowball. At the top of a mountain, that was really painful with my hands making that cold little ball. As I was rolling it down the hill, eventually it caught momentum. When it catches momentum, then you're just guiding where it goes. That's what makes it fun.

The successful recruitment of PTs starts with a powerful mindset - where you're at cause to finding quality PTs. Click To Tweet

Can I share with you an experience that I remember you telling me the switch that went off in your head? You would go to the student health fairs or at the local PT schools. You had your table there and the other guys had their tables there, the national guys and the large local chains, they all have the tables there. They all had the students lining up at their tables, but then there was a switch. You told me about a change in mindset that you had in and it switched from all the students lining up at their tables to now everyone lining up at Rise Rehab’s table. If you remember, at least what you told me, if you changed your mindset from, “Hopefully who would want to drive all the way out here,” to “Who wouldn't want to? We have an amazing company.” Maybe you can elaborate on that a little bit.

I'm trying to bring that up because as I was speaking into this process and it's true. There was a degree of it that were gradients, but there was one moment when there was a major mindset shift for me and after that, it's when we started building a bench. We went from trying to recruit one or two people a year to our new company Empower that Rise Rehab was put in, last 2018, we hired sixteen physical therapists in eight months. What happened was I went to one of those self-improvement things. It was on a meeting and I realized how my mindset was limiting. The fear of never overcoming it dissipated. Who I was a totally different person around it. I can talk about tactical things all day long, but the most important shift was that piece.

I was acting like a guy who was frustrated with recruiting all the time. It showed up in my efforts, to being a guy who felt confident that I was going to make the difference in the life of a physical therapist through my company. I did have to have some sort of foundational work to be able to feel that way, but there was a day where I shifted and the next week, I hired two PTs that I had zero lead generation on. I went from meeting them to hiring them in two weeks. For me, that was more than they would do in a year. Who we're being in recruiting is a big part of it because if we're frustrated with it and we're irritated that the last person didn't work out, that's going to show up in who we're being as we're talking to new people.

I remember I made some off comments and it was a comment that we'd made with each other over the years. It was like, “It's hard to recruit in those roads in the city.” You and Michelle turned around immediately were like, “No, it's not.” It’s almost like I had to apologize. I'm like, “I'm sorry.” That's the mindset I recall. You shifted from, “It's not hard to recruit out there anymore.” You took a definite stance to say, “It's not hard. We just need to find the right people and we will.” I recognize you found some amazing people that came into the clinics and they'd started bringing their friends.

That goes the snowball effect but you're right that there was that moment that there was a shift. It's so funny because you don't have to go to a seminar, in my opinion, to get that epiphany. I love the realization that we have. All of that potential in each of us, we just have to tap into it. The way we do that is by being clear with our intention. What is it that I'm going to be creating here? It takes a little self-confidence too. It's okay. We're struggling with that but ultimately to make a decision, “I'm going to kill this thing.” It's not enough to say, “It's going to get easier over time. I'm going to go find someone tomorrow and it's going to work out great.”

That happens with so many things and it's not just recruiting. I was talking to a guy who's not even in physical therapy school and he called me and he's like, “What should I start doing to be successful physical therapy owner in the future.” I was like, “Don't worry about the ownership stuff and don't even worry about the PT stuff, get your mindset right first. Go and read, Think and Grow Rich and maybe Rich Dad Poor Dad or something like that. Get your mindset in a position where you're empowered. That you are at cause for all these things. Get your mindset right first and then you can deal with the tactical stuff later.

PTO 55 | Recruiting Physical TherapistsI love that you said that because it's so true. Our industry is so riddled by the fear that I think that's how it shows up is in things like recruiting because we typically see things like anything, “sales related” and recruiting a sales activity like our first visit with a new patient. We see that as bad because we never want to be in it for the money. The truth of the matter is that fear, when overcome, is what changes the lives of our patients and therapists. One of the phrases that I'm taking a stand against is in PT school, we learn from day one that our license is our livelihood. That phrase is a load of crap because there's a lot of people out in this world who don't have a physical therapy license who can provide for their own living. We are our livelihood, not our license.

Our licenses are our opportunity. That's the distinction. It's like trying to win a game because I'm afraid to lose versus wanting to win. That was me in recruiting. I was afraid of losing time away from my family because the longer it took to find someone, the more I was away from home. Pain in hiring the wrong person because I wasn't confident I'd bring the right person on and the management headaches of bringing them on with such a nightmare. When I was recruiting, because I was afraid of that, it's what produced it. When I let the fear go by saying, “This is stupid. I'm going to go create a great company and find good people regardless of the state I'm in,” then we started finding them because they were attracted to that energy.

We talked about mindset, but we have to talk about some of the tactics. A lot of your success has been with students and working with the schools, but you can't get all of it too. Tell us a little bit about what you're doing maybe with some of the schools and maybe if that's progressed to doing a little bit more to actually get 32 providers in the last number of months.

We've hired 34 physical therapist assistants and PTs.

Talk to us a little about what you're doing with students and anything else that might be tangential to that.

When I started operating from a place of being at cause, I saw my role being a mentor and a coach. That's really how I approach this process, is that I am there to help people find their home, whether it's with me or somewhere else. That's a powerful distinction because I tell them in the first visit, I'm not trying to hire you, I'm here to serve you. What I would like to do is find out who you are and what you're about. I have a network of people that I have. This happens all the time, that there are people who I would love to hire, but I know it's going to be a better fit for them to be somewhere else. It makes it seem like I'm a good guy when I do that but it's very selfish because in those meetings with any PTs, whether it's a student or an experienced PT, when they hear that, they are immediately drawn in and if they're supposed to be a fit in my company, they land beautifully.

If they don't, it ends up working out somehow. It does. I trust the greater powers that be, that by being in a state of service to these people, things are going to work out the way they're supposed to. It takes so much anxiety off of me to realize that it's not my job to convince anyone to join our company. It's a big thing because I'll show you how that shows up in things like job fairs. At the core of who I'm, as I sit down and I tell them even after they join our company that my job is to help them find their next job, whether it's in my company or not. I hope it's my company, but that for some reason when they get feedback, they see that that's what really resonated with them is that commitment to the individual and the process and not an outcome.

I can be witness to that. You and I both have hired and fired people and the people that we have fired, we've actually made recommendations and called a few of our friends around town saying, “I’ve got these physical therapists. He's not working for us, but if you're looking for somebody, I'm going to vouch for him.” That really means a lot to them. We're not burning any bridges, but we're actually doing a service to the human that's part of our team and no longer part of a team. We want to help them move along and find the right place because we're not going to be the right place for everybody and you have to understand that. I think it's really a tribute to you too because one of your tactics at the fairs that you go to is to offer some of those students some trial interviews. You say, “I’ll sit down with you and we'll go through a typical interview process. You can practice your interview skills with me and I’ll give you some feedback.” That has a secondary purpose. You really find some gems in the making.

A focus on service to and relationship with every candidate attracts the best providers to your company. Click To Tweet

That's when things got really fun is when I realized that I was there to really serve the greater good and my patients became the therapist in the world. I used to treat and serve patients and alleviate their pain. Now, I'm doing that full-time with physical therapists, physical therapist assistants and anyone who shows up. I don't personally recruit entry level positions anymore. I have one person, one very special person, Toni Williams, who is masterful at all things talent development. She personally does hiring for all 27 locations of Empowers’ company. She personally hires every single person. I had my weekly check in with her, she has zero openings. I do want to brag on this, in our company as a whole, we have 27 locations, we have one opening right now. It's a physical therapist opening. I have a lead that I can tell you now, we're going to close him.

I'm excited to say that after our merger is at a point where we'll have zero openings and any position in our company, which is pretty fun considering at Rise, we used to have at least three or four we’re constantly working through. That's only four locations. You brought up the student thing so I’ll jump into that. Once I saw myself as a coach, it changed how I sat at job fairs. First of all, everyone's standing behind their table and they're waiting for students to come up to them. Forget that. I'm there to serve. I'm not trying to attract people. I'm attracted to them. I'd have someone with me stay at the table and tell them to stay in front of the table. The second thing I did and this is going to sound a little gimmicky, but one of our three cultural values is fun. Our cultural values are family, fun and freedom. If it's fun, it’s not work. We've got this big prize wheel and everyone can and they can spin the prize wheel and it was really silly. It would be like there's a Starbucks gift card, there'd be like pens, a candy bar and there'd be like a slap on the face.

I’ve got to tell you the side story. We have like three other serious prizes and then there'd be a long awkward hug as one of the prices they could get. I had to stop doing that though because we started spending a lot of time hugging people and it got weird. As you said, there was an offering and that offering, again, if it's done from a place of trying to convince people, it's going to look like a gimmick. Legitimately I say, “I offer two services. The first is, I'm doing free job interviews. I want you to sign up. What's different about this is this will count as your first job interview. What's different is we're going to give you feedback and we've designed this very specific structure that's come from books and experience of how we give feedback around it that is so powerful.”

Our mission when we have a student step into that mock interview is to change their life. Oftentimes we have them in tears and it's because we're in this space of creation with them versus trying to convince them. Another thing is a real servant isn't going to distinguish between the third year and a first year. Those third years are getting attacked. No one's even paying attention to the first years. Those are my favorite ones to get to. First of all, they are like deer in headlights. They walk into those job fairs. They feel like they're supposed to. No one's really paying attention after they find out. Those are the ones I sit down and we get real clear on their future because if I'm serving them, the earlier they get that information, the more it's going to serve them their whole student experience.

What's funny about that, and you can imagine, when we hire one of those people, they come in as almost director level by the time they get to me because during the year, one of my other offerings is I’ll coach them on leadership and that's where I’ll take the books that you and I have read and that we've been a part of all of our time. I'll put them almost always immediately on good to great on a whole series of books based on their interests and what they want to go create. We talk about it every quarter. Every week I interview, no kidding, five or six students, whether they're first or third years and I don't hire the vast majority but I serve all of them. That has built into annual speaking opportunities.

I'll speak at all the different colleges here, the four different schools in Arizona. I was honored to be the keynote speaker at their student conclave where they all come together. I'm not there to promote Empower, which I believe is the greatest company on the face of the Earth. I'm not there to do that. I let Empower create its own buzz. I set the example by serving and that's how we've been able to grow. Our feedback after being open for less than a year, we've had two people leave in ten months out of 27 locations that said it was the merger of our locations that was the reason for leaving. Those were individuals that frankly I didn't think aligned with us. Our retention has been phenomenal despite all the changes we've made. It's been a lot of fun.

PTO 55 | Recruiting Physical TherapistsYou talked about having a bench and we had that in Rise Rehab. We were constantly hiring. I want you to speak to that a little bit because we got away from the positions open, put an ad out. It’s a type of frame of mind that we have that we typically have. We're only putting a lot out when we need somebody. I'm assuming and correct me if I'm wrong, you've got an ad out all the time. You said you don't have any positions that are opening. That probably stems back from when we were hiring all the time for the admin staff that we were always trying to hire, but now you're hiring all the time for PTs, PTAs and you probably you’ve developed a bench simply based on your relationship with the schools and some of the first and second years that you're talking to.

The bench concept is a really interesting one and it's very real and to prove that point, we had a therapist move out of state two weeks ago. They resigned saying, “I'm moving out of state. I'm getting married.” They resigned on a Thursday. We had a job offer out Friday and they accepted Monday for a rural area in Arizona. It was at one of the more rural areas. That bench concept is where you generate a lot of power. What I would say about generating a bench is that you're always recruiting. You always have ads out. Another thing I’ll do is I do a love letter, is how I call it, to the physical therapist in Arizona. It's not like romantic or anything, but it means basically talking about like what we're doing as a company and what openings we have. Every time I do that, we generate a couple of hires from that. Every state is different. In some states, it’s physical mailers, which statistically, it’s actually is proven to be a better method. It just costs more money.

I use MailChimp and then the Arizona database. For a price, they'll give you the current PT registered list through the state. It's 3,000 people and I’ll send out an email saying, “This is what we've got open. I write them in a way as if I'm coaching them.” It's like, “First of all, I hope you're happy where you are. If you're not happy, I’d like to meet with you.” This is true. Every time I get a PT from that email, the first thing I try to do is help them resolve their issue at their current employer's place. I don't want someone who can't resolve their own problems. If I sit down with them and they're like, “I'm unhappy at work.” I’m like, “Did you talk to your boss?” They're like, “No.” I'm like, “Let's talk about that. What is it about you that isn't being powerful to go solve that issue?” I hated that when people left my company and didn't even tell me why that they were unhappy. It was the worst. I've saved a number of relations in the valley with employers who don't even know that it was their “competitor.”

It speaks to the service that you provide and to go back a little bit, the power behind the constant promotion for an ad or for any position in your company, it brought to my mind the conversation that I had with Brian Weidner. He's a PT recruiter for Career Tree Network and I had him on. He had some great insight, but he said there are two types of candidates that you're trying to attract. There's the actively looking and the passively looking. The actively looking won't have a job or they're students. The passively looking are like, “I wonder if the grass is greener. I'm happy at my current place, but I'm wondering what's going on out there.” They're the type of people that are looking on indeed to see if they're making as much as the rest of the people in the region or they're like, “I wonder if there's another setting or I don't like my EMR and this is going on for a couple of years. Maybe there's another place that I can check out where things are easier,” but they're passively looking.

It's hard to attract the passive ones because 80% of the PTs are happy where they're at, especially in Arizona, they could go any place they want and find a better place. It's important to keep that ad out there because you never know when the actives become passive and vice versa and you don't want to wait for the perfect timing when you need somebody and they are actively looking at the same time to merge and all the planets align and you find that right person. There's some power behind the constant ad process being out there.

I would say because I hear myself ten years ago, listening to this going, “Great. Now, there's another thing I should be doing that I don't have time to do.” What I would say to that person is to remember that at my size with 27 locations and being a minor partner in that, that’s my role so I get to live in that space full-time. When we had four locations, I didn't have to spend a lot of time on it. I had to be really focused and precise as to what worked and nothing is more empowering or beneficial than that mindset thing you brought up at the beginning, like “I'm going to find someone.” If you allocate an hour a week or 30 minutes a week and work on an ad, work on a mailer to be Arizona or your state PT group or just researching the job fairs. What I’ve learned by talking to other companies as we've looked at acquiring other practices is most people don't do jack squat. It's hundreds of times more powerful than nothing

Plan it out. It really doesn't have to be a lot of time. You create the content once and you can run it for a couple of months probably or the job fairs aren't every week. They're like once a quarter maybe. Once you plan for one and you get all the swag for one, then you have it covered for the next couple of years probably. You can float around and play around with how you're going to do things differently. You put in some initial efforts to create content and create your setup. After that, it's just pushing the flywheel and keeping it going. You can always filter out the people that you don't want to see but if someone amazing comes across your desk, it's nice to be in a position where you say, “I don't have a position for you right now,” or we've had this before, “You're an amazing person. We don't have a position in a company for you right now, but we're going to bring you on anyways and we'll find a place for you.” That's pretty cool.

If you build it, they will come. It's so true. If you've got the right who, the what makes sense afterwards. We're not saying too and I make sure people understand this, is that I'm always top grading. If we find the rock star and we have someone we've been questionable about, we make a change. That's the way it works. If another employer offered a better position to one of my team members, shame on me for not pivoting and being a better company. It works the same way. The bench thing is interesting because what I’ve found is when we absolutely can't make it work, we keep those relationships up. We send out a six-week email to them, checking in with them no matter where they are. We've developed some incredible relationships with people we've never hired and coaching opportunities. We've helped people negotiate salaries and reviews and those kinds of things from a distance that these aren't people who even work with that were there to serve still because we're committed to these people as long as they want help.

The biggest mistake you can make in talent acquisition is a surprise post hire. Click To Tweet

You're committed to the relationship, whether it's in the company or without and that goes a long way. You have a sincere commitment to that and that shows up. If we're talking about tactical things, anything else that's come up that seems to have really helped you or is it simply the focus on relationships?

Relationship-focused, summarizing what I talked about and then adding that the piece I haven't yet. Mindset shift number one there is to serve and coach and that looks like meeting students where they are. Any PTs, where we can find them, whether it be active or passive, through ads and communication to the state board. What I would say is once I get an interested individual and I’ve coached with them, I don't pretend that I have all the answers. I struggled. I had done well with the Rise Rehab when we merged and I started doing poorly again. What I realized was at that scale, I needed to leverage other great people to reinforce the positive story about Empower. When I started with Sean Miller, Matt Figueroa and then we have regional vice presidents.

We have Kyle Davis and Michelle Bambenek, these are individuals who, after I'd have this powerful first meeting, I'd send that person to them to show up at the clinic and have them observe the clinic. We tell our future employees, that's our way of providing our references to you. Go ask our team members, what's the best thing about here? What's the worst thing about working here? We want people to know where we have our struggles. The biggest mistake you can make in talent acquisition is a surprise post hire. The biggest mistake I’ve ever made is either me or them being like, “I didn't expect this.” That's when it goes to crap. By providing that, it was a huge piece for us because it reinforced the story through other amazing, high talented individuals, but then it also created clarity and transparency that allowed our future employees to really see us. Sometimes that means they don't join us. Every time that's a gift.

I remember one time, we were recruiting a physical therapist that we knew would be great and she's still with us now, Jody Maluski. Remember we brought her to the company party for one of our clinics. That's where we recruited her and she sat there with the Maricopa team and got to meet some of them and some of them came over and said, “This is a great place to work for, you ought to join us.” Just to show her a little bit of the culture I think was huge, personally, but also to have them go onsite and see the offices and do those job interviews onsite and hang with the providers and meet their directors. That can all be a great benefit to both parties for them to see what's going on and how you guys work. Number two, for us to see how they interact with people and socialize.

You hit it. I'm so glad you brought that up, Nathan, because it is in my mind now, I consider finding talent very easy because physical therapy as an industry, we understand what you said. You go outside of our industry and the people that make the company grow, they get taken out to dinner. They get soft handed through that process. If we want to stand out, take someone to lunch. It's mind-blowing, but no one does it. You take them to lunch, you bring their spouse. You're hiring a spouse every time. You're not just hiring the individuals. You bring the spouse and you see how that dynamic works with other work family members. I love how you stated that. It gives us a chance to see them and how they interact with other rock stars.

You shared a lot of great information. I appreciate it. I've referenced a lot of the work that you do. I was like, “I need to have you on and get it from the horse's mouth.” It's nice to get to get it straight from the source. You've done amazing. Your division within Empower Physical Therapy is a strength by far. You can imagine how weighed down they would be if they were looking for four or five, six PTs constantly. Being in the position that you're at now is huge. It's because of all this work from the past that you've built and the relationships that you've built, you've done a lot of hard work to get there.

PTO 55 | Recruiting Physical TherapistsI sure appreciate that. I acknowledge that comment, as well as acknowledge again Toni Williams and the amazing leadership team we have an Empower. I get to take credit for a lot of other people's powerful influence on what we do and even yours. You and I, we cut our teeth together and that's why we're who we are with each other now. With what you're doing up there, it helps create space for me to do what I'm doing down here. It's always a family effort and it's been a wonderful education as well.

I think I'd be remiss in saying that a lot of this stuff that you've done has not become procedural. You've created systems behind it so to go back to the effort that it takes to move this along, now it's a matter of following the procedure. Job fairs coming up. You've got a laundry list of items that you know you need to prepare and you go and do it and everything's covered and it makes for ongoing success. I'd be remiss if I didn't point out to the audience that there are a system and procedure. You're not making it up on the fly every quarter for every job fair. You've got it all dialed down.

I would be more than happy to speak to anyone of your readers, to dial in their systems. As I said, coaching is what I do. It's what you do and the opportunity to serve another person who was me ten years ago is the coolest thing. It’s like, “I've been there before and yes, it sucks, but it also gets better.” If any one of your readers does call me this, be prepared to spend a lot of time talking about their mindset.

How can people get in touch with you?

I'll give you my emails. My email is WillHumphreys@me.com. My work email is WHumphreys@EmpowerPT.com. Just email me.

Thanks man. I appreciate you sharing. Again, thanks for your time.

It was so much fun. Thanks again, Nathan.

Important Links:

About Will Humphreys

PTO 55 | Recruiting Physical Therapists Will has been VP of Marketing for Empower PT from August 2018 - May 2018 with a focus on Talent Acquisition and Development, which he continues to do and specialize. He has developed a strong relationship with the PT schools throughout Arizona and is proud of the support and coaching he has provided physical therapists and physical therapy students.

 

 

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PTO 53 | Provider Production

 

Shaun Kirk, PT is back! Our last interview with Shaun has been the most listened-to episode of the podcast over the first year, and he's got more to share! He discussed the six areas of practice that all owners need to be aware of in our first episode. In this episode, Shaun shares with us the three areas of provider production that need to be addressed. It's easy to see when a PT in your practice is doing well with patients – the patients are getting better, they're creating good bonds with patients, and their patients are happy. However, that's not all they need to do. Their relationship with the patient means nothing if they're not documenting and coding appropriately, two areas that will hurt you more than it hurts them if they fall short. Be sure to track all three of these areas as they could disrupt the integrity of your clinic and leave "holes in your bucket."

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Listen to the podcast here:

The Three Areas Of Provider Production with Shaun Kirk, PT

I have Shaun Kirk returning as a guest on the show. Shaun's episode that I did has been one of my more popular episodes. I'm excited to bring him back so we can learn a little bit about what Shaun has been doing over the past year. He has met with a number of clinic directors and clinic owners across the country. He has been able to build off of the Six Key Areas that Physical Therapists Need to Address, which is what we talked about in our previous episode. He, however, also talks about how to improve productivity with your physical therapists. This is valuable information that we can get into. He brings us up to speed on what he's been doing, why he's doing it and also we addressed those six key areas and productivity in physical therapists. You'll enjoy the show because he's got a lot of wisdom to share.

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I'm excited to bring Shaun Kirk back onto the episode. Shaun was one of the most listened to episodes that I have. It’s great results because he shares a lot of wisdom. Thanks again, Shaun, for coming on to the episode. I appreciate it.

Thanks for having me, Nathan.

What have you been doing? What are you up to nowadays? We'll get into a little bit about some wisdom that you can share for us.

If you haven't heard that episode I've done in the past, check it out. I get into a lot of color about where my life started and how I ended up where I am. What I had been doing for the past several years is prior to these last several years, I've had a consulting company, Measurable Solutions for about twenty years. We’re working to help practices grow and expand. I enjoyed that a lot. What I liked about it was working knee-to-knee with the practice owners and helping build their team, strengthen their goals and helping them achieve them. As the company began to expand and grow, we grew into three locations. My role changed to where I was much more administrative and a little more distant from all of my clients. There are some few I stayed close to but got distance because it's a bigger organization to run. I had an opportunity years ago to take another look at what I wanted to be when I grew up. I thought, “Maybe there's a different game where I can work closely with the practices.”

This opportunity came along with a private equity group in the mergers and acquisition area of physical therapy businesses. It was a brand-new startup. They liked me and they liked what I brought to the table. I ended up being their first employee. Now I believe they have about 1,100 employees. We have about 180-plus locations in about 26 states. It's been a hustle. I have been busy working with these practices and traveling quite a bit. Although I enjoy it, it's not quite the same. One of the things is as I've learned a tremendous amount of data I didn't know before, even though for twenty years, I've been working with practice owners.

Before that, you were a practice owner yourself.

I was a practice owner before I went out and started helping other people how to practice. For me, as a consultant in the years past, one of the things that I never get a chance to see, Nathan, is your EMR. I don't see how you're coding things, your staff or billing in general, what their documentation looks like. None of those kinds of things do I get a chance to see. When I have this new opportunity, we own our own EMR software. I have the ability to see a lot of things and dive a lot deeper into practices from an operations point of view. Over the last years, I've been working with these practices on making a couple of internal adjustments. The best way you can look at it is if you have a bucket and the bucket has holes in it, you can pour a whole bunch of new patients into the bucket, but you still have holes. You're going to have a lot of leaks. If you pour enough water in, so to speak, your bucket will fill. How economical is that?

What I've learned more is a lot more things I didn't have in my toolkit but how to close the holes in the bucket. I truly have enjoyed that. What I miss is that relationship, working with private practice owners. What I've been doing for the last several years, I thought I wanted to help clinicians and prior practice owners reach a whole new level of the game, open up other clinics underneath them and build something great. What I truly found is that I can't knock anyone interested in doing a move such as a sale or whatever. What I can say is that I liked helping private practice owners reach their goals versus helping investors reach theirs. From that, I decided I'm stepping out of that world and back into the consulting arena again.

There could be so much more joy for you. I don't want to put words in your mouth, but you're going to help this guy grow his practice, whether it's stabilizing his practice. When we say grow, we're thinking that everything is going to get better. I love your analogy about the holes in the bucket because there are so many guys that have these ideas that they're going to get three to five clinics. I'm like, "Your one clinic is barely getting by 10% profit margin and you're burning yourself out. How do you think you're going to get the three to five? You've got to fill the holes in the bucket." There's so much more joy to see that guy succeed, grow his practice and become an independent owner of something larger instead of seeing that happen for the benefit of a corporation. Is that where you're going with it and get excited about?

It is something that gets me excited. You've known me for a while and to me, it's always about relationships. You build those relationships when you have clients who genuinely know you care for them, and you're interested in them and their life. If you happen to have the worst practice in the area, but you work 90 hours a week, is that something to be proud of? Not really. It’s making something grow, expand but that quality of life hopefully it can give you. People always think that their practice will give them freedom. They'll go out on their own. They can call their own shots and work their own efforts. It can happen and there are ways to make that work. That to me is the key thing. I have a client in Florida I loved dearly and a good friend. I remember when he sat down in front of me and I said, "What would you like to achieve in your practice?" He said, "A lot of people talk about money. I don't need to make a lot of money, but I would like to be comfortable. You don't have to make a lot. I would like to be able to achieve that without having to be in the office. I'd like to live on a boat." That was the weirdest thing.

His practice grew from maybe 120 to 250 visits. He was able to do that with not having to physically be in the clinic. He lived on the boat for about a year. He went on a long sales trip and he came back and said, "I'm done with that." He sold his boat. He's got a second clinic. He has a whole new set of goals. If one's goals don't include more than how big their wallet is or how many visits they are seeing or whatever, what's the reason why? What's the reason that you're doing it? For me, when you work in this somewhat cutthroat environment, it's never good enough. The world I'd been in the last several years has not been about you as the clinic director or prior practice owner. Create something and have some free time, some great things with your family and all that stuff. You are having these terrible conversations and it's not about the quality of your life. That's what I missed because that's the relationship part of what glues me to this profession.

Tell us a little bit about what you're going to do next. What's your next game?

You don't need more patients if you have holes in your bucket Click To Tweet

If you ever have a chance to have a mulligan, you think about yourself and your practice. If you wanted to do it all over again, there's probably a laundry list of things you would probably want to do differently. I don't know exactly what those would be, but if you think it through there probably a few things you would have done differently. For me, this mulligan moment gave me an opportunity to take a business that I've built over a twenty-year period and look at the things that I loved about it and things that were not so great about it. Unfortunately, because that's the way your machine runs, it's not easy to go, "Let's quit doing that. Let's do something different." Starting something new is different.

One of the things that we would do within the company is we had an introductory course called the New Patient Course. I know that you've been to it before. It's a two-day course. It's hopping on a plane and coming to one of our offices. You're missing at least three days of work. It's a great course. It's helped a lot of people expand and grow their practice. It's a big commitment. You're losing quite a bit of time and money for something that you're not sure if it's going to work. Over these many years of working with practices, I have gobs and gobs of do this and don't do that. Try this, it works 97 times more often than not, I was going to help you. What I decided to do in this new endeavor is to build things around a mastermind group.

Tell us a little bit about your ideas with the mastermind group. It's a concept that I pulled from Think and Grow Rich by Napoleon Hill. There are plenty of accountability groups out there that are another word for mastermind where you get a group of people in the room and you discuss the blank topic. Sometimes it's similar industries, sometimes it's not. Yours will be PT-specific. Tell us a little bit about your mastermind concept.

Several years ago, while at Measurable Solutions, I put together a group called The Master's Club. In that Master's Club were many of our top clients. What it became was a bit of a mastermind. Mostly I would present a topic, we would talk about it, how to apply that, issues related to that and those types of things. It started out with a couple of guys and then it began to grow and grow. It was something I liked about it because it was like getting down to the nitty-gritty. These guys have done a lot of training and in their own right very successful. It's having a point of view that's not in your practice, somewhat exterior to your practice, who's seen a lot of clinics and can go, "Over here in Rhode Island, these guys are doing well.” I've seen it work and I’m like, "A light bulb goes off." We're very close to that. We didn't have that one little special sauce you mentioned and we'll put that into the practice. That was a cool thing. I know it's buzzy and popular. Everybody's doing it. I get all of that. There's accountability all the way around. That's what I wanted to build with this.

That definitely happens when you’ve got multiple guys in a room. If it's one-on-one, sometimes you can be as that person, but when you’ve got two or three other perspectives and they're like, "Why are you saying that? Why are you telling us this story? That's not necessarily how it works where I'm at because I see something different." Getting the different perspectives and the different mindsets together can be helpful and coming to the truth or even brainstorming can be beneficial.

I've delivered hundreds and hundreds of seminars and workshops. Every now and again, you'll be delivering a workshop and someone will raise their hand from the audience. He'll go on and spout on about how he does things in his practice and it works amazing. They get tons of referrals. Doctors love them and all this stuff. The rest of the audience doesn't know that I know that practice isn't winning. I know that practice is barely profitable. Others are writing it down like it's the gospel. How does that work? Five morons don't make a genius. You want to be able to earn the right to the table.

In the mastermind, you might have people with small practices. You might have people with big practices, but what we have to be able to do in this mastermind is you need to back up what you're saying with some statistics and actual objective data. All of my mastermind members are in a statistical management program. We have a two-hour call every month and a follow-up call every month with individual practices. Let's say we're taking how to set up the standards of care or we're taking up how to get internal referrals. We take that subject up. That would happen to be a tremendous amount of content in that area and there will be an implementation program with the intention that it will take a part-time basis under 30 days to get put into your practice.

Nobody wants something that's going to take a year and a half to get into your practice. It's bite-sized chunks, “Get the numbers up. I want to see the stats rise.” It's all about driving the practice growth. For a couple of reasons. Who doesn't want instant gratification? I'm afraid all of us do. If something takes a long time, it's easier to give up on. It’s like, "In two years, you're going to triple your practice," forget that. How about two weeks? It's dissecting down to a key couple of things. When you're on their one-on-one, if you're a big practice, you can take a bigger bite out of things so that program could get deeper. For a smaller practice, you might take a small bite. If anyone listened to my first presentation, there are only six key areas of practice, whether you're big or you're small. Each one of the masterminds deals with one aspect of that experience.

PTO 53 | Provider Production
Provider Production: If one's goals don't include more than how big their wallet is or how many visits they are seeing, it's never good enough.

 

My little mantra is, “Reach out, step out and network.” Reaching out means to find some consultants or coaches. Stepping out means get out of full-time practicing so you can work on your business. Number three is to network and there are different ways that you can network. Entrepreneur's Organization has an accelerator program that my partner, Will Humphreys and I used. We also are part of the Master's Club that you talked about. Networking with other PTs, even other industries can be beneficial to get some mindset, some mind melding, brainstorming and different perspectives. This is all hugely beneficial. Can you share with us a little bit about what some of the content might be in a mastermind situation?

One of the things when we take on a new client and we start working with a new client is you can't keep doing the same thing and expect a different result. If you have a practice that has holes in their bucket, the most common thing people think is, “I need more new patients.” If you close the holes, you'll get more patients. You could get a better outcome or word of mouth. A lot of things will happen. You'll be more profitable. Also, your marketing dollar goes a lot further. Closing the holes is key but to do that, you have to change behaviors. It's not always the owner. Sometimes you can get the owner to change his point of view, but he can't change the rest of the team's point of view.

I don't know the ladies in this audience, but I do believe that I have a good understanding of the men in the audience. Whenever there's something that we can't quite face at work, some person we have to talk to and we think it's going to go bad or ugly. When we lay in bed at night, we become Chuck Norris, Walker, Texas Ranger, you all know, hopefully you've heard that name before. You're lying in bed and you've got this staff member who comes in late, cuts out early and doesn't get his notes done. You're mentally clicking off tally marks like, "Six times he's done this. Seven times he's done this." Finally, you get to the point where you're tired of not sleeping and you need to say something to him. You're like, "Joe, it’s not okay that you're coming in late." This is what you're having a conversation mentally. You're lying in bed and you're going, "Joe, it’s not okay that you're coming in late." He goes, "You can't talk to me that way.” “As a matter of fact, I can." He says, "You're not the boss of me.” “Yes, I am. I am the boss of you." He takes a swing at me. I docked and threw him on the floor, cuffed him and tossed him out the window. While we go through all this mental pain all night long, Joe is sleeping like a baby. He's out cold. He doesn't have any awareness that he's this type of staff member.

You finally muster up the courage to go into work the next day and you go, "Joe, it's not okay that you're coming in late." The next thing you know he's apologizing. He says, "Ever since Mary had the baby, I'm not getting a lot of sleep. I'm so sorry." He gives you a hug. You're wondering how you get your karate chop. What I'm saying is you have to set the stage. In this mastermind, we talked about what are the standards of care? A staff PT has to do three things. He needs to treat people well and get great results, that's a given. You can usually see that if you're in the clinic. You look and you go, “Happy patient, range of motion improved. Now they can walk on their hands, all things are good.”

The next thing is they’ve got to code appropriately. It's not lazy, not pick two codes and whatever number. They have to code correctly for what they're doing. The third is they have to document it impeccably. They have to document it and back it up because number one if you guys are good therapists, it gets great results, he has happy patients who love him or her. They're referring people in. It's all good. If he doesn't code well, the owner takes it in the shorts because they're not getting paid as well as they could be. If he doesn't document well, there won't be any blowback on that therapist. It will only go back on the practice. What you see is a great therapist, what you may not see is what goes on in the EMR. That was one of the things that were significant to me that I learned when I was with this PE group is looking in under the hood and seeing there's a lot of room for improvement in this game. In that particular mastermind about setting up the standards of care, it would be everything from how to code to how many visits, the discharge, different things that are expected on every patient and gaining agreement and cooperation from your clinical team. Once they embrace that, on other mastermind groups where you get together, there are the mechanics of the actions to take to achieve all of that.

An effective promotion will lead to new patients. Click To Tweet

Like you shared with me, you collect a lot of those statistics beforehand so you knew what they were doing and this is what you've been doing for the last few years. You'd look into EMRs and find those statistics. You shared with me also that a lot of these owners that you're talking to think they know where their stats are, but they don't know the true data. They might say, "We're coding and fine. We're doing great." You look at it and they're billing two skilled units of visit for a one-hour treatment." You're like, "You're giving away 30 minutes of free therapy. That's not right. That's not ethical." You're also losing me money at the same time. I love that you get into the nitty-gritty about, "We need to code appropriately. We need to back it up with appropriate documentation because our license might be on the line, but I also get dinged because an insurance company could find out about it and pull the contract.”

That happened to us by experience. It's not all about the therapists. If they can treat, great. You can develop great relationships. If they're not doing their part as a team member, it brings the whole boat down. That's where the holes are that you're talking about the buckets leaking like crazy. You're not in a position to be stable and get the freedom that you want, that you're talking about beforehand. Especially if you want to expand, you've got to shore up those procedures in that regard if you're going to expand and make this more than a two, three-person clinic.

It is about building a team. Sometimes you have an owner with a big viewpoint, big goals and big dreams and you have a staff who doesn't know and agree with those big goals and those big dreams, you have a disconnect that takes place. I see this a lot where clients would get the two owners in a room, there are the key execs in a room and they'd talk about world domination and all these things they’re going to do. They never talk to the staff. Those are the guys who make it happen. They are like, "How did it go with the staff meeting?” Sometimes we take too big of a bite when we're not ready. Sometimes when we're ready, we can take massive heights and we open a clinic. There are people who open clinics and don't show up until it's open. They're not even a part of it because they have such a great leadership team. Those are good and you're fortunate to create that, but not everybody is like that.

You bring that up, I remember I was probably five to six years into my ownership. I knew that I needed to hit about 180 visits per week for my one practice to break even and make some profit. It was in a slow season, we got down to 150. I told my main therapist, “We only got 150 visits this week.” She looked at me like, "What does that mean? Is that good or bad?" She was still going and checking log. That cued me into finally recognize that not only should I know my stats, but my staff needs to know the company stats and their individual stats if they're going to get in on this together.

There are a lot of assumptions that are made. Some of the times we don't do a deep dive very often and looking at how our numbers are shaking out. You talk to almost any private practice PT and you go, "How often do you see your patients?” “I see them about two to three times a week." Do you know what I'm finding with all of these guys that I've been dealing with when I first started working with them? It's about 1.5 visits per week. When you have this data and you go over this, what's funny is that they don't believe it. 100% of all the partners that I've been working with, when I go, "You're 1.52 patient visits per patient per week,” “That's impossible. The data is all wrong."

It's not wrong. It's like, "There's got to be a miscalculation in the system." I go, "Why don't you manually do it for the last week?” How can that be? It can be for any number of reasons. We can sort those out. It could be as easy as the therapist being a softie. It could be the patient has a high copay and whines about it. The receptionist is a softie. It could be the therapist wants to see you three times next week and the patient says, "I can only come once." The receptionist says, "Okay." It could be a million reasons. You don't know why, but the number is not very good. The lower the frequency that you see a patient, the more attrition that you'll have with that patient where they'll discharge themselves.

I've always said if you have more pain in your wallet than pain in your back, you're going to quit therapy. If you give a long pregnant period between treatments, it's very easy for a patient to discharge themselves. Within the mastermind, you have to start with data. Everybody is filled with opinions, "You know what I think I should do?" It's like, "Why are you having a conversation with me? Why haven't you already done it if that was the solution?" We have to start with raw data. We gather some raw data and the data will point us to something. That's what we'll do in each of the masterminds. That's what we'll do with a one-on-one. We look at your data. We see where it points. What are the action steps that can be taken in a short period of time to influence things in a more positive direction?

PTO 53 | Provider Production
Provider Production: If you have more pain in your wallet than pain in your back, you're going to quit therapy.

 

What do you tell those guys who might say, "I don't have three hours a month, I'm treating a full patient load 50 hours a week and doing my business stuff on nights and weekends?" You've heard that for the last 30 years. What do you tell them?

I tell them that it's probably always going to be that way. As long as you're okay with it, I'm okay with it.

What if they don't do something different?

It's okay. If you work 50, 60 hours a week and you manage on the weekends, you don't have a life and you keep doing that, then you're going to work 50, 60 hours a week and not have a life. If you're okay with not having a life, it's not my problem either. If you want to change that, some things have to change. That's the key. Some things simply have to change.

As you go through the masterminds, do you stick to the six areas that we talked about in the first episode that I did with you? Do you focus on those areas specifically and highlight some of those each time you visit each month?

Let me run off the six areas so that I put out lots of details, but to give you an idea. The six key areas of practice success as I see them is an effective promotion that will lead to new patients. That mastermind could be almost anything marketing. It could be several different masterminds on that subject. Whether that's social media, whether that's remarketing, whether that's direct mail, whether that's how to survey your public to find the right message to deliver. It could be on a variety of different things on a high gradient, a low gradient and a medium gradient. That would be a subject. Another is your schedule work control. Getting people to keep appointments, scheduling out into the future. It gives you many predictions of expansion and it creates growth. Schedule work control would be number two. The next is mastering patient compliance. WebPT did a study where 70% of patients discharged themselves from PT.

I did an interview with Heidi Jannenga and they did their state of therapy report. I want to say the average clinic lost $150,000 a year because patients didn't complete their plans of care.

Don’t work with people who aren't willing to put their shoulder to the wheel. Click To Tweet

That's a good number. If you have a patient that finishes therapy not well because you didn't have the spine to have the conversation, they go somewhere else. You don't lay around like, "My back is killing me." You're going to go find someone else whether it's another physical therapist, whether it's a chiropractor, a massage therapist, an acupuncturist, a crystal hooker, whatever it is, you're going to go search out some care because the person didn't get it done. When we look at case acceptance or patient compliance, looking at closing the patient on the value of the service and receiving it and it's sales. A therapist who is a softie on sales never built a profound reputation in their community because most of their patients are half-baked, a little doughy in the middle.

They're not completely crisp. You can't build a reputation when you don't push it through. That's the third area. The next one is your competence in management, billing and collections. Certainly, that's the actual process of billing and collections. Certainly, it's those types of things. It's also coding correctly. That would be in the category, whether we're doing a visit-based coding such as Medicare or whether we're doing procedure-based coding such as AMA. How are we coding our care? Our EMR will do the calculations all for you. If you are sloppy in this area, you're losing buckets of money in practice. That's the fourth area. The fifth area is getting referrals from your existing patients and to me, that’s the gold mine of PT. Most practices, about 50% or more of what they see are old patients or friends with patients, which is fantastic. Who doesn't like a referral? They come in and they think you're a god before you've even said anything to them because their friend, Sally, said you're amazing. Yet, we do very little. Some therapists do this crazy thing where they say to the patient as they're discharging and leaving the clinic, "I hope I don't have to see you again." If you do that and you're reading this, stop it.

I had an interview with David Self of Keet Health. He swears that if you improve that customer experience and that includes the referral basis and developing that internal marketing, you would triple your ROI on your marketing dollar. If you focused on that, you don't need new patients. You need to improve the customer experience, focus on internal marketing and your marketing dollar will triple.

One thing I find too in this one particular area is when you treat people in a closed environment, they become patients in more than a physical sense. You become their counselor, their priest and all these different things that go along with that. One of the things they don't get involved in is the community of physical therapy. They are not involved in like, "Seeing this guy, he was limping before and now he's walking better." They're not part of that dynamic energy that goes on generally in your gym. You look at that and you start evaluating against us, it's normally not hard to do. I've definitely done some looking. When you start evaluating, not like this group therapy delivery but within reason, you don't want unclothe people walking around and are like, “You don't need pants here.” In more of a dynamic environment like that, it's hard to be the depressed whiner in an environment like that. It brings you up. Whereas if you haven't been a room, they think they're the only patient that you ever have. They hang on to your time and you never know what's going on. That makes a difference in terms of building internal referrals.

Generally, the sixth key area of practice success is improving the productivity and efficiency of each staff member. In this area, it's broad. How many visits do you need to see before you hire a tech or a PT? Where do you need to hit numbers-wise to justify the next hire? How do you evaluate the performance of every individual in the practice so that you can see that they're pushing the rock up the hill and you can see by how much? You know when you don't need somebody is when they go on a two-week vacation and nobody had to pick up anything while they were gone. When they come back, they don't come back. How do we improve the efficiency and productivity of every staff member?

One of the things, Nathan, is we look at an efficiency statistic. We talk to every practice and you say, "How many visits would have a full-time PT in a week?” It's a full-time schedule. They start doing the math. They’re like, “They get a double appointment for a new patient,” and they start doing all this math. Let's say they come up with a number of 60, even number and they say it's 60. You look and go, "Where are you?" They go, "Let's see." You do the math. You go, "How many PTs do you have?” “I have three PTs." I go, "How many visits are you seeing?" They'll say, "We see about 90." That gives you a 50% efficiency, which means 50% of the time, they aren't doing anything productive. If that therapist goes back from a workshop, seminar or mastermind and says, "Guys, 50% of the time we're not doing anything," that percentage is going to improve because someone is going to quit because they're mad at you. That's a management strategy, but people will not consider that they're inefficient.

They'll fill the time. They're not sitting around twiddling their thumbs. They're going to say, "I was documenting. Remember that, for our staff meeting, you wanted me to present. I was doing that and I called some patients." They'll fill the time that's available to them. It just won't be productive.

PTO 53 | Provider Production
Provider Production: Make sure you don't over-hire unless the stats supports that you bring on a new person.

 

They won't like to start playing Euchre or something like that. Maybe they do. They don't and no engine can run at 100% either. You can't be flat out all the time. There's somewhere in between. I remember being in Maryland visiting a client about fifteen years ago and 86% of his revenue went to salary. He was paid lower than the lowest-paid PT. While I was there, three staff members reached out to the owner and said, "We need help in billing. We need another therapist for such and such." He goes, "Let's get an ad out." I looked at the staff member and go, “No, don't do that." The staff member looked at me, looked at the owner. He goes on, "I'll get back to you." I go, "What are you doing?" It’s like being big, powerful and lots of staff that are inefficient is ridiculous. You can't take care of your staff. The staff who's working hard, you might have one working hard, you can't take care of them because you've got seven of them that are doing 50%.

You'll eventually lose that one because they'll get burned out. For people who are wondering, we try to keep our salary as a proportion of our income. It’s less than 50% if we could. If you can do that, you're doing well. If you're at 45%, you're killing it. Try to keep it around 50% on an annual basis, then you're doing pretty good. 86% is horrific. That guy has got a lot of holes in the bucket.

In some areas of the country, if you're upstate New York, it's more challenge. When you reimburse at $46, $48 a visit, you’ve got to hustle. When you're in that environment, you figure it out. If you're in different environments in Chicago land area, Maine or whatever where you might be pulling down over $100 a visit, you can have a lot more sloppiness in your game and still survive. It is a changing environment. Rules change and people won't be making more money if they're funny that way. How do you do that? You can do it in a controlled and agreed upon fashion or you can cut back to where you're not even delivering great care anymore. When we look at improving productivity and efficiency of each staff member, we're looking at the other five things running well, good promotion, good schedule control, good patient compliance, coding appropriately, billing appropriately and getting internal referrals. If the team pulls that off, they're generally very efficient and productive. You want to make sure we don't over hire unless the stats support we bring on a new person.

I love that you brought up stat simply because the key to all of these things is typically statistics 90% of the time. To know if you're doing well in any one of these key areas is to know the stat related to it. In that way, you're not objectively saying, "We're doing great. I'm seeing two to three times a week," when they're 1.5 simply because you're going off your feeling or, “So and so is my best physical therapist and his patients love him. Meanwhile, he's only producing two times a salary when he should be producing three and a half to four times.” You have to have the stat in order to recognize what is happening in the business and drill down on those.

I got this line from one of the gentlemen that I work with the PE group and I love it. I have to give him some ownership to it. When you're keeping statistics, it’s like reporting the news or are you creating the news? If I'm talking to you and I'm like, "Keep the statistics on. That doesn't do me or whatever.” Are you just reporting the statistics? Are you reporting the news or are you creating the news? Creating the news takes skill as easy to spit out a bunch of numbers or software and give it to you. It’s like, “How do we create the news?” and each staff member creates the news for his respective or her respective area. It's not, “I just turned in the numbers for the week. There are my numbers and they stink bad but those are my numbers. I got turn them in. I got them in on time.” It’s like no. You have to be accountable to create the news. That's what we make a shift for. A lot of practice owners and myself included at one time, you spend a lot of time when you're trying to implement something into your practice. You don't even realize you're doing it, but you spend this time with them mentally or with your partner hashing it out. It's basically, “How do I close my staff to do this? What are we going to say in a staff meeting that's going to get people excited about this?” Did you really go through that, Nathan?

All the time. We know these stats, we know these things and we have these programs. How are we going to get the practitioners or the front office staff to buy in? It's getting the water down to the end of the row if you're a farmer.

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You had an owner who wants to take big bites and big bites fast but the staff doesn't want to take any bite at all. That's part of where the mastermind comes into play. We take a bite that's easily digestible across the hole. We get that in place operational consistently there versus, “Do this,” and it's huge. The guy who gets all excited. He hangs up the phone and goes, "How in the world am I going to get this motley crew to do that?" What one or two or three little things can be taken at a time where we’re beating the elephant one bite at a time and we're growing something that you can look back and be proud of?

In the mastermind, the way I have my mastermind is you can quit at any time. I'm not locking you down to pay all up front, all of this kind of weird stuff. I'm not doing any of that because if it's not for you, it's not for you. On the other side of that coin, I don't want to work with people who aren't willing to put their shoulder to the wheel. There are always those guys who will sign up for something because they got more money to burn incense and they get involved in it. They say, "That's some good information," yet when it comes to application, they don't apply it. It's like those bizarre patients who never missed an appointment. They never get better and never do their exercise program. They won't run it with a gun in your hand. They keep coming in. They suck the life out of you.

Unfortunately, you can occasionally have clients like that. Within the mastermind that we have, you come in and we interview you. If it's going to fit and you want to do it, we sign you up. If we don't think we can help you, we're not going do it because this is already capturing attention and growing. What I loved about what I did before was I love working with people who wanted to change things. It was exhausting to work with people who were mostly unable to face their staff, situations at the office and they’re mostly whiners. I don't want any whiners, I don't want any spectators. Instead of locking them down like, "I paid for a whole year so I better show up to this thing," they’re coming in like Eeyore in Winnie the Pooh. It's like “It's not working out. I'll fill your seat with somebody else who wants to play ball." I'm interested in creating 5,000 award-winning clients. You don't get there when you got a lot of hangers-on.

Shaun, thanks so much for your time. I appreciate it. If people want to get a hold of you, find out more about the mastermind that you’re doing or just asking more questions regarding what you’re up to nowadays, how can they get in touch with you?

Probably the easiest way would be email. Just email me at ShaunK@PTPracticeSuccess.com. You can also give us a call at 866-220-0386.

I hope a lot of people will reach out to find out exactly what you’re doing and also find out more about the programs that you’re offering nowadays. That’s going to be a huge value to anyone who reaches out.

I think it’s going to be great. It’s going great already. It’s nice particularly in this web world where you can actually look at somebody and say something and the light bulb goes off and you get to see it. You can’t see that over the telephone but you sure can see it in a web environment on a Zoom meeting or whatever.

That’s the beauty of technology. Thanks again for your time. I really appreciate it.

You’re welcome. Thank you.

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About Shaun Kirk, PT

PTO 53 | Provider ProductionAlliance Physical Therapy Partners is supported by a very successful private equity group. Our strategy is to partner with private practice physical therapists by making a sizable investment in their practice and help them to build their brand.

We do not change the company name, owners or corporate entity. If you are curious, I would suggest that I connect you to our Director of Business Development who can assist you.

My role with Alliance Physical Therapy Partners as the VP Operations is to work directly with our partners to assist them in expanding their practices, identifying other practices in their area that could be "tucked-into" their practice in order to build their brand. In short - help our partners reach their goals, create growth in their practice while creating a best in class experience for all their patients.

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