There is no perfect formula for growing and expanding your PT business, but as with most other industries, the way to learn is to look at those who have been there and succeeded. Jeff Ostrowski, PT is an owner/partner of 35 clinics across SE Pennsylvania, starting from a single clinic 30+ years ago. Over the years he has taken on partners, added more clinics, expanded existing clinics, and merged and purchased other clinics. He has experienced almost all the possibilities for a growing and expanding practice. Nathan Shields brings him on the podcast to discuss some of the most frequently asked questions about PT business expansion, such as "when is the best time to add another location", "when is the best time to add another PT", "when should I consider adding more square footage", etc. Jeff has been through enough over the years that he knows what has worked for his growing company. Listen in as shares his insights on the podcast.
I'm excited to bring on Jeff Ostrowski. He is the Owner and Partner in Excel Physical Therapy in Southeastern Pennsylvania. They have 35 clinics and continue to grow. We'll get to his story, but I want to bring him on about some important topics in regard to growth and expansion that a lot of new owners and even long-time owners have questions about. He has been around the block a few times. First of all, Jeff, thanks for coming on. I appreciate it.
You're welcome, Nathan. It’s good to be on the show. I enjoy your show. It's good and helpful. I'm glad to contribute.
Thanks for being a part of it and for taking the time. We haven't met each other that much. We talked on the phone a couple of times, but you've got a lot of wealth of knowledge and wisdom. I know you are a big part of the P2P group and PPS in getting that established. First of all, thank you for your efforts in doing that. That's huge to establish that kind of networking and network. It's a great resource for the physical therapist. Thanks for doing that.
You're welcome. It's a wonderful resource for private practice owners. If you have readers that are PPS members and they're not in the Peer2Peer Network group, they ought to join that too. I've been involved in PPS for a long-time. I was on the board of directors for seven years and the editor of IMPACT Magazine for three years. I served on a whole bunch of different committees and task forces. Like you said, I've been around PPS long-time and this Peer2Peer Network thing is one of the most valuable things that I've seen come along. I want to do a little endorsement for everybody who's reading. I certainly can make myself available to your readers to talk more about it if they have questions about PPS or Peer2Peer afterward.
Tell us a little bit about you. You've been in the industry for some time. You've been an owner for a while as well. Tell us a little bit about your professional story and what got you to where you are with such a large company.
I started the practice back in 1990. I've been a practice owner for many years. I've started by myself. I brought on one of my best friends and business partner within a few months of opening that up. We grew that up and then we merged with another company in our area back in 2011. That was a great experience. It was an awesome company that we merged with. We've had good success. We probably doubled the size of the company since we've merged. I've gained a bunch of great friends in those partners from the other business that we merged with as a result. We took what was good about our company and their company, put those things together with a lot of humility and no pride of authorship.
I took the best of both worlds, put them together and created something special in our industry and that's where we are. It might be of interest to your audience that I’m semi-retired many years ago. We hired on a management team, CEO, CFO, some regional directors and some other management talent to run the day-to-day operations of the company. My partners and I were able to step out of day-to-day operations and move into a retirement mode. We still work. We're on the board of directors and we handle special projects in the company and do stay very involved and very aware of what's going on, but we have a good leadership team in there so we're off doing other things now. It's pretty neat.
Congratulations on getting to that point. Through your experience as an owner, you've seen all the stages, it seems like. You've not only brought on the next PT, which was your friend, but you also opened up another clinic. At some point, I'm sure you had some leadership team that you guys worked with either before or after you merged with the other company. It seems like you've gone through essentially all the steps of building a corporation so you can go back and give us some good advice.
There are two things we can talk about there when it comes to growth, what's known as the same store growth. That's how do you grow a clinic from 1 to 2 to 3 therapists and so on and then there's the growth through a new clinic, startups, de novo clinics. There's a lot of different nomenclature for that out there. There's the growth through mergers and acquisitions, but I think our success has been in the first two, in the same store growth and then opening up new clinics. There are lots of similarities between the two.
Let's start from the beginning. For a lot of physical therapists, whether they're new or have been around a while, if that initial step of going from one PT, which usually is the owner, to bring on that next physical therapist, bringing on that added expense then, “How am I going to keep them busy? What am I going to do? How am I going to offload patients? How am I going to rent myself back up? How do I handle all that?” What would be your advice for that initial step to bring on that other physical therapist?
I'm reflecting on the days when I was the only PT and the practice was growing. It was extremely exhilarating at that time because patients were coming in and I was like, “I can't believe people are coming in here and I'm having so much fun. I'm enjoying this.” Although we weren't very good, we are getting paid back then. It was a great time to grow. It does take a certain trust or jumping off the cliff to bring on the next PT because I fully understand the mentality of, “I'm the owner. It's my name and reputation at stake here. I don't know if I can find someone to do it the same way that I want it done.”
A lot of times the owner is very overwhelmed with day-to-day. They're seeing tons of patients and then they also have to run the business and they don't necessarily have time to invest in training new staff, a new PT. Even hiring seems pretty daunting sometimes because you have to interview and it's a very competitive market to hire therapists in the last several years. It's tough. You got boxed into a corner and the way out of that is a couple of things. Number one is in this day and age, the schools, at least in Southeastern Pennsylvania near Philadelphia, are putting out much more qualified therapists now than they have since I can remember. The PTs that are coming out of school are ready to work. There's been an improvement and advancement in the profession as far as that goes.
You still have to train them. You’re still going to manage them, monitor their performance and their statistics, but it's much easier than it was many years ago, in my opinion. You have to be capitalized too. You have to have some money in the bank because when you bring that new therapist on, it's going to put you underwater financially for a while until you can get their schedule filled up with patients. They're self-sustaining in terms of their contribution to the revenue of the business or the clinic. You've got to be ready for that. Meaning, you have to have some cash reserve. You have to have very carefully mapped out financial plans and budgets so that you know what you're up against and what your cash position is going to look like as you bring this person on and you ramp that up.
That probably gets in the way of a lot of people early on. It certainly did for me. I didn't understand the idea of capitalization as much as I do now. You've got to have that. A mistake that's often made, if I look back at my history, I can see it very clearly is when times are good and your schedule and therapist’s schedule is filled, you can be very profitable in that area. If you watch closely, you will start to see signs of stress on your business. When everybody's schedule is filled up, you'll start to see your charges per visit go down. You'll start to see the time that patients wait to get an appointment starts to increase. You'll start to see that patients don't schedule as frequently as they did on a per week basis.
You also start to see that your quality measures and there are many of those. There are outcomes measures, Net Promoter Score and patient satisfaction. You'll start to see those things slip a little bit because when it gets busy, patients don't get as much attention from your therapist. They don't like it as much when it's busy and although the owner right in that zone can be very profitable, that is short-lived, because what happens is all the hard work that they have done starts to fall apart. During that same period of time, they probably slow down their marketing a little bit because everybody is busy and you don't have time for it and that falls off. You then get on this up and down roller coaster phenomenon and you never break through to that next therapist in your clinic.
That’s one of the reasons why I push some of my clients to consider bringing on that physical therapist because they, as the owner, need the time to manage those things. Our natural tendency is, “I am productive when I'm seeing patients.” That changes when you have an ownership hat and a lot of those holes in the bucket start forming as you take your eyes off of the business. One of the things I try to stress is to make sure that you know your financials. Talk to your CPA or bookkeeper often so you know exactly what hit that PT will make on your business.The amount of time that you spend in your policy, procedures and training gives you a huge return that doesn't show up monetarily. Click To Tweet
You can get certainty on what the environment's going to look like, but also have a little bit of faith knowing that this is another investment. When you started your business, there's no guarantee that your business was going to succeed. There's no guarantee this other physical therapist is going to succeed. When you do bring that physical therapist and it gives you time to work on the business market and be carefully managing all those statistics that you're talking about, then things can go much more successfully. You can grow successfully as well without slipping in all those areas that you mentioned.
You said that well. I'll add to that is as the owner who can't get to that next level of managing the business because they're so busy, they're overwhelmed and they're underwater. They start to not like it. The owner gets tired, burned out, jaded and cynical. That early enthusiasm that you had when you first opened your doors quickly, you get beaten up. That starts to go away after a while and you get embittered. That has cascade throughout your company. It's you, as the leader of the business are showing up for work every day with a negative outlook and a bad attitude and, “This is horrible.”
It's hard to attract and retain good staff when you have that kind of mentality. When you go home to your family and you're all salty about how bad your day was, maybe you feel like kicking the dog. If you had one, it will be hiding under the bed when you walk in from a day's work, but it's definitely not fun to live that way either. I can tell you this from experience and a lot of your readers probably have lived through this too. That's a very important part of all this. We want this practice and business to enhance our lives and not detract from it.
The stress of hiring that first PT and this is my theory that I've built up over the past couple of months. You're going from one PT yourself to two PTs. That's a 100% increase. The stresses could be about the same, at least financially. Maybe that's not a 100% increase in your expenses, but it's a significant change in your expenses. Going from 2 to 3 PTs, that's a 50% increase and it's not as hard to bring on that third person. It doesn't hit the expense account as much. As you add more physical therapists, the expense ratios are a little bit different, but in doing each of those steps, as long as you keep your eyes on the business and train your therapists appropriately, recognizing that you need to step back in your treatment availability and time spent. You can do that successfully and each subsequent hire can be a little bit easier to tolerate both in terms of money and energy. Do you find that to be true?
That's exactly right. You spread out the overhead of the business over more revenue-generating PTs. Each one has less of an impact on your bottom line if you will. As you're doing that too, you're developing systems, whether they're marketing systems or operational systems, hiring and training systems, so that each time you bring someone on, not only is it easier financially to bring them on, but you have systems in place that makes it easier to get them onboard and productive as quickly as possible. Those are key things. Those investment and building training systems, especially building, hiring systems, having a marketing program that runs on autopilot so that you're not running around with your hair on fire all the time with those other things.
That's one thing that my company had been very successful at. My partners are amazing. We've spent a lot of time putting those programs together. My one partner, Todd, could be one of the smartest hard-working guys I've ever met in my life and probably is. He uses this ecology, “Your business is an ecology,” and everything works together and contributes to the health of the whole organization. It's not one thing, it's a lot of everything and they all need to work in alignment. That sounds like a lot of big words and it sounds easy to do. It's not. It takes time and effort to build all those things, but those investments pay off extraordinarily well once you get them in place.
That's what a lot of young owners or newer owners don't recognize is the amount of time that you can spend in your policy and procedures and time spent on training materials is a huge return that doesn't show up monetarily. It is multiple times more productive than treating that patient. It is a grind to put some of that stuff together, but for the sake of the business and for your mental health, it's a huge step in the right direction. It makes things easier.
It's another reason why an owner who wants to grow can't be gobbling up all their time treating patients because these things that we discussed, it all takes a lot of time to put together. If you're 40 or 50 hours a week in the clinic, you're not going to have time or the energy to do this other stuff.
In terms of stepping, not just into adding another physical therapist, what advice would you give to owners in terms of considering moving up to a significantly larger space or finding another location? Is there a formula that you've used in the past, in your company or yourself to say, “We're performing at such and such rate? Now is a good time to expand, get a significantly larger space or a new space altogether.” How would you address those situations?
Let's talk first about the larger space. There are some metrics out there that people use in terms of a square foot per full-time equivalent and they're all over the place. Those metrics depend a lot on what's the payer mix, net payment average per visit in your market and stuff like that. That's going to be very individually based, but it's the same mentality that I described before when you bring on a new PT. If you're going to get to the point when you walk into it, first of all, it's going to look and feel very busy. There's a buzz in the air.
You might have patients waiting for pieces of equipment. You might have patients waiting longer in the waiting room because there's not enough space for everybody in the building who is who's coming in. You will also see that manifest in your statistics and the same thing is going to happen. You're going to see the visits per referral are going to start to go down because people don't like being in this busy space. This happens a lot. The therapist also feels very busy and they feel bad about that for patients. I've hired thousands of PTs over the years and we want to go to work and have success. We want to be able to take good care of people.
Most of us went to PT school with this vision that, “I want to help people. I love this profession. I love what I do. I make a difference and it feels good. When I go home at night, I might be tired because it was a long day, but I feel I lay down at night and put my head on my pillow feeling like, ‘I did good work.’” That feeling is what we want to capture here and preserve and fight to preserve. If you try to cram a lot of patients into a small space and the schedule is busy, the PTs don't feel like they can have success. They start to not feel good about going to work after a while. They get burned out and they don't do their best work. It's nothing conscientious that they do. It's just a natural erosion of their enthusiasm.
It shows in the statistics.
It absolutely does. The patients come in 1 or 2 less visits than they would before. Their cancellation rates go up. The friend and family and past patient referrals that you were getting before might start to go down because people aren't as happy with the care as they once were. You might have more turnover amongst your therapy staff. Watching those statistics in the same way, it'll point you to the same exact thing like, “We're bursting at the seams here. It's time to take on some new space.” That's a tough decision because most of the time, you're going to be signing leases that are about five years on average. You've got to map out your growth for five years to make sure you don't run out of space in a year.
Again, you've got to have good financial planning, good budgets, good advice and a good understanding of what your growth rates are going to be so that you know that if I have three therapists now, several years from now, I'm going to have 6 or 7 in this clinic. I need maybe not 2,500 square feet, but 5,000. It's like you described before when you hired that new therapist on. You're going to have a little suppression in your cashflow in the beginning until that therapist builds up. It’s the same thing with taking a new space. You're going to have to budget it in there, “We have more space than I need for a while here until we grow into it.” That's how we always looked at it in terms of taking on new space.
It's very much about feel, but a lot of the feelings do translate into the statistics. Patient compliance goes down a little bit, therapists aren't pushing the patients to come 2 and 3 times a week. They're okay if the patient only comes once a week. They're not seeing the results. Whatever your measure is, whether it's your square footage or your efficiency, the number of appointments that are filled on a PT schedule on average. If you're running about 80% to 90% clip on a routine basis or regular basis, then that's a good time. If you continue to work hard at that pace, people are going to get burned out.With the right people on board, growth comes easily and becomes inevitable. Click To Tweet
It's a good time to consider either a larger space or if you are looking at another geographical location nearby, that's a good time to do it because you don't want to do that when you're running it 60%. Even though you might have these great ideas, “There's this perfect location over here that I want to open up.” You don't want to extend yourself and open up that new location or get that greater space because it's a great opportunity if you're not maximizing the efficiency of what you currently have.
That's going to put you financially underwater. It's tough to resist those temptations. You've got to optimize your current setting before you go expanding into new locations. There are a couple of things that are important. You need a referral base there. You need to know that there's going to be some patients that are willing to come in and maybe some physicians that are willing to refer. I think the most important part of a new clinic is the leadership of that clinic. Who is going to go in and run that clinic? That goes back to your hiring, training processes and leadership development. Because I think you could take a perfect location with an average leader and you'll have an average result and conversely, you could take in an average market location, put a strong dynamic leader in there and you'll have a fantastic result. The leadership development piece of this is absolutely critical.
That builds off of a comment that Steve Anderson made in the previous show. It’s exactly what you said. Even in the Northwest where he was, they found when they open up clinics, it wasn't the location so much that they were looking for as much as who. First is who then the where or the what. Once they established, “This person has been with us many years. We vetted. They're a high producer and they have the desire. We've worked them through the leadership management program that we have or whatever that might be. Now, that we have the person let's go look for the location.” Whereas some people might say, “I've got the perfect location. I need to find somebody to fill it.” That's not the way to go.
That's great wisdom by Steve. He's had great success. I couldn't say it any better. It's the person first, the location second.
Did you ever purchase clinics even in a young stage where you might've had 2 or 3 clinics and then you’re looking at possibly purchasing another?
Yeah, I have. I've purchased two other businesses in my career.
Tell us a little bit about that. Looking back on your experience, what advice would you give owners nowadays? Honestly, I've got a couple of owners who even at their current size one, maybe two clinics talking with or being approached by people locally in the community who are looking to get out. What advice would you give yourself in that scenario when you're considering possibly purchasing something at a young stage?
This is a financial discussion. You have to map this purchase out financially. How are you going to pay for it? How much are you going to pay for it? How are you going to pay for it? Can you afford it? The difficulty that most acquisitions run into or acquirers run into is the integration of the business that they bought into their business. In my experience, it's much harder than I thought. It takes longer and it's more expensive to integrate. You've got to put all that and factor that all into your financial planning. You may find when you do it that it's more advantageous to go and open up new clinics and hire new therapists than it is to buy other businesses.
We've learned some hard lessons in the acquisition area. We’ve made 1 or 2 mistakes with some acquisitions, not accounting for the integration costs. There’s also this cultural piece of it. You run your practice one way and this runs a little bit differently. How do you put those two together without alienating the people and having to start over again with hiring new people and all the rest of it? Tread very carefully here. It's very sexy to go out and buy businesses and it's a way that some of the big companies in our industry are growing dramatically through acquisitions, but the difference is they have capital partners. Meaning they have a lot of cash to use.
They have teams of people that integrate businesses and they have a lot of experience doing it. How a business is going to fit and how that's all going to work much more than smaller practices do? I don't want to discourage people from doing it because it's done and I know people that have done it successfully. The smaller you are, the more pressure it's going to put on your organization financially and culturally. You got to go take it carefully. Don’t fall in love with the idea of it without falling in love with the financial side of it first.
I talked to a friend about that because he was considering the purchase of a clinic. I said, “There are simply pros and cons to it.” When you're looking at purchasing a clinic, you're buying a book of business that is running. It probably has referral relationships, has contracts and has a team that's already working. You want to be tight with a good CPA that knows about mergers and acquisitions. How to read financials and teach you about it as well.
The cons are the things that you may not consider when you're talking to a CPA and that is, “Is it a cultural fit? Are you value-aligned? How's the team going to take it if I manage them differently? Are the benefits going to be the same? Are they going to lose if I purchase them because my benefit package is different than theirs?” There are many things that you might not be looking at right off the top, where maybe the pro of opening up your own clinic instead of purchasing one might be a better way if you simply have the right people. It's going to cost less, but you don't have the immediate revenue flow that an established clinic might have. If you have the right people, you will stand that and you can be very successful.”
We know this is a people business and this happened to me. I've had patients call saying, “I want to see Joe.” “Joe's not here anymore, but you could see Mary. She's a good therapist. We have her.” “I like Joe. I want to find Joe. He was my guy. He's my therapist.” It's a people business. Patients tend to follow their therapists. If you're buying a business where the owners or the staff, for whatever reason, decide not to stay with the new business, you're going to regret the fact that some of those patients are going to go away. That's something you've got to factor into it too. There's going to be some loss of patients there because it's a people business.
That brings up another thing. To go back in terms of stages and where owners are at with ownership, how do you deal with stepping out of treatment care and telling patients who liked what you did, especially when you're the owner and your partner that you were no longer treating? How did you make that transition and highlight your staff? You wouldn't tell them, “I've got a great staff and I've trained. I'm still on site.” You want to almost allay their fears, especially when the referring physicians are saying, “I want you to go see Jeff.” In my case, they almost didn't remember the name of my clinic. They said, “I want you to go see Nathan.” They knew that I had other physical therapists on staff, but that's how they knew of my clinic because I had that relationship. How did you successfully make that transition out and tell those patients that wanted to see you?
That was a tough one. I remember that I was very nervous about that. I know a lot of owners are because you feel like you have an owner mentality and you're probably a good therapist, number one. Number two, you have this owner mentality where you take good care of people and you relate well to people and all the rest of it. To get out from under that is difficult. You're going to have some loss during that period of time. There's going to be some patients who are upset by that, but I found it was very few. In the beginning, I would have to talk to every single one of them and say, “I picked this person that you're going to see. I trained them. They do it exactly like I do. In fact, in some cases, they're better than me for A, B and C reasons. However, I will be watching and monitoring. I'm always here for you when you need me.”Once you’ve build a reputation for your business and your practice, it will see you through even in times of transition. Click To Tweet
The vast majority of patients were willing to take that leap of faith and trust with me if it was explained that way. The physicians were the same thing. I remember those days with the prescription. They don’t say, “Go to Excel, go see Jeff.” It was the same conversation. I had to go to each one of them and explain, “I am getting busier. I am growing. I can't see all these patients. Can you allow you some of your patients to see new therapists that I bring on?” Most of the physicians were fine with that. They understand completely because they're in practices that are growing too and they understand how that works. Sometimes, they would want to meet the therapist and then that was cool.
It was a great marketing opportunity. Eventually, the prescriptions or referrals, they didn't say see Jeff anymore. They said, “See the other therapist.” That was a great day for me. I was very proud when that happened. There's nothing better as a PT that when you develop your own reputation, were physicians and patients identify you as a therapist and it's an awesome feeling. It's something to cultivate in your staff and that creates great culture and great momentum. It enhances your reputation as a business and practice when that word spreads that way.
There is a lot of anxiety and fear in making that handoff, but I think a lot of it honestly is pride because you have results. You've built something up and that could be the one thing that’s stopping you from making that jump is thinking, “Everyone's coming to see me.” There's a little bit of a pride element to that because it is what you've established for maybe over a few years.
Not a lot of good things happen when you're too prideful. I've learned that lesson. It is trust. You have to trust other people. Some of the trust can be built by picking the right people and training them properly and your trust level goes up and you do that.
I never tell that to people that I'm talking to that you've got to get over your pride. It's more about laying their fears. There might be people that will stop seeing you, but that means that they have to go to another place and establish a new relationship. I don't know if a lot of patients are willing to do that if they're that upset, but there is that possibility that there's going to be a few. I say, “Brainstorm and work with your front desk,” because they have to believe the story that they're telling patients that call them and say, “I want to see Nathan.” We need to figure out a story so that they are completely confident and believe the story that they're telling the patients, otherwise, it's not going to carry very well.
You build a reputation. If you lose a therapist or you bring on a new therapist, the reputation of your practice, if it's cultivated, nurtured and worked on all the time, it will carry you through those transitional periods. That goes back to where we started this conversation about having the systems in place, investing in training, accountability and management and how do you fix a PT who's off the reservation with one of their statistics and get them back on the reservation. How do you pick the right people with the right values that align with your practice? That's the ecology that my buddy Todd always talks about.
With you, as an owner, I'm assuming you went into it without a lot of business experience. How did you learn the statistics, numbers, measurements, how to develop policy and procedures and hold people accountable?
I had a little bit of a knack for it because I had that analytical brain from a statistical perspective, but along the way, I've had some mentors. I have a friend that is like a brother to me. A guy that I grew up with who got a practice up in North Jersey. He started his practice right around the same time I did. We helped each other. I learned a lot from him. That was one thing that helped me. I have a couple of consultants along the way. I moved into a new neighborhood many years ago and I got to be real good friends with one of my neighbors and he had an engineering business, but then he went into financial consulting.
He was the first guy that set me up on the whole P&L statements and balance sheet and taught me how to read and look at all those things. That was Brian and he changed my life at that point because that was when I finally though a light bulb went off about how to run a business. A couple of other PTs that I've had along the way. Kim and Michelle come to mind. People that were good with organization, administration and details. Edward was another one, a sharp guy. When we merged with the company I mentioned earlier, they had a lot of intellectual property in terms of systems and financial statements that took us to a new level.
Not knowing your story that much in-depth, I assumed that there was a point at which you came across someone who could teach you the ropes and you could get some training. My mantra with the show is if you want to expand, grow, get the freedom and profits that you want, you have to step out and meaning step out of training, you have to reach out and find some coach. Executive coach or consultant to teach you how to run a business and you have to network and work with other people who might be in similar situations, even if they're not in physical therapy. I assumed that it was probably part of your formula as well.
Our industry has a huge array of very talented consultants out there. There’s plentiful advice out there that you have to pay for. In many cases, it's worth it. It certainly was to me over the years to pay for that advice. It's your tuition. You can learn it the hard way. We're smart people. We can learn it, but why not take advantage of what's already out there? Even in PPS back to the private practice section, there's a wealth of resources in there. There are all training and different tools for marketing, finance, operations and so forth that weren't available many years ago. We have come a long way. I want to give some more accolades to PPS. The taskforce, work and tools that they put out during the COVID-19 crisis and pandemic was an amazing work that the board did during that period of time. That stuff is all still available. If there are people out there who are still working through recovery, which most of us are, I'm going to point out PPS and say there’s a lot of good tools there for you to use.
Looking back on what we've covered and we've covered a wide expansive of growth avenues, is there anything you want to go back and add to, or anything you want to add here towards the end of the program?
When you're busy in a clinic, that's a point where you're probably making good profits because you're busy and everybody's loaded up with visits. That could be a very attractive place for an owner to try to live because the profit margins are high. However, that's going to come with consequences that things are going to start to break. It is inevitable. When you're super busy, things are going to break. Watch those statistics, everybody. If you're starting to see those pressure points start to break down, that's a sign that you need to hire on new therapists or expand your clinic because you're going to start to come down the other side of that and your profitability is going to start to erode and you're going to spend a lot of money to build it back up again. Keep that kind of growth curve going smoothly up into the right and not herky-jerky rollercoaster-ish. That's the key to success.
Take that as your cue to take the next step and then take that step in faith, knowing that what you've done so far has been successful, continue to add to it. Thanks so much for your time. It was great talking to you in sharing your wisdom, your knowledge and your great help. I appreciate your work with PPS and Peer2Peer. If people wanted to get in touch with you or reach out to you individually, are you willing to share your contact information?
The best way to reach me was with my email. I'm happy to answer emails and if I don't know the answer to it, I know a lot of people out there. I can put you in touch with them. They would probably do know the answers. My email is JOstrowski@ExcelPhysicalTherapy.com.
I recommend people reach out if they have questions. You're available and you've got plenty of experience in the space. I appreciate your time. Thanks for coming on.
Thanks for having me. You are doing a great job. I love what you're doing, love this profession and there's so much opportunity out there for us if we work together and we share our knowledge. There's a wealth of opportunity out there. We're doing great work. We have value. Let’s grow this pie as big as we can and we can all get a big bite of it. Good luck, everybody.
Professional: B.S. in Biology Juniata College, Huntingdon, PA 1984. Graduate of the Thomas Jefferson University Physical Therapy program, 1986. Founder of Excel Physical Therapy, 1990. Partner in E&A Therapy, 2011-present. Licensed Physical Therapist in Pennsylvania 1986-present.
Volunteer: Board of Directors of the Private Practice Section (PPS) of the American Physical Therapy Association (APTA) 2011-2017; Treasurer PPS 2017-2018; Managing Editor of the PPS APTA member magazine Impact 2008-2011. Past President (2011-2014) of the Southeastern District of the Pennsylvania Chapter of the APTA 2011 -2014; Board of Directors of the Pennsylvania Chapter of the American Physical Therapy Association 2011-2014; past member of the PPTA Finance Committee 2014-2017; PPTA Legislative Ambassador Key Contact; APTA PAC Ambassador in Pennsylvania; APTA and PPS Legislative Key Contact.
Personal: Lives in Glen Mills, PA, a suburb of Philadelphia; married with two children, ages 23 and 21; Enjoys sports, fitness, cycling, golf, drawing and reading.
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Eric Miller of Econologics is back on the show with Nathan Shields to talk about money. His episode, released a couple months ago, is the most listened-to episode in the two-year history of the podcast, discussing what PT owners needed to do financially as they slowed down during the Covid-19 pandemic. Now, as clinics begin ramping up, he's back to discuss what owners need to do to re-establish their financial foundation and set themselves up to weather any future downturns. He lists five accounts each owner should establish and the mindset needed to establish wealth. It's simple yet takes consistent effort and intention.
I've got a returning guest, one of my favorites, Eric Miller of Econologics. Eric, thanks for coming on again.
It's always a pleasure and a privilege. It's good to see and fear the beard now.
Also, be jealous of your tan. You are doing well down in Florida enjoying the sun. It's great to have you back here, our favorite financial planner. I love going to you for advice. In your episode, we talked about financial management through COVID-19 is by far one of my most read blogs. You shared some great wealth of knowledge, but we're in a different space. People are still hurt. They're not running at peak efficiencies. There's somewhere in the 40%, 60%, 70% productivity range. Private practice owners are gradually getting back into play. Some might even still be shut down, but we want to talk about what we can do to reset financially. I've talked in past episodes about resetting business-wise, our goals, purpose, marketing strategies, how we see our businesses and getting back into them the way we want to build them back up again.
Let's talk financially about ramping back up and reestablishing some fundamental aspects to our financial foundation in our business. That will do a lot of us good as we start looking forward. I know you're going to talk about this, but to summarize, we're going to talk about PPP loans, how to use some of that money and how to eventually be in a better position to withstand these issues going forward. Let's start with some of the PPP stuff, to begin with, unless there's something you want to get off your chest right away.
The whole idea is that we have to get the attitude that we're all going to try to get into financial beast mode. Let’s forget we're trying to get by. Let's have the idea that we can get in financial beast mode, which is a term that we're starting to use a lot more. Let's up the game a little bit. Let's up the intensity of what needs to be done to get our financial house in order.
It does so much for you to be financially sound, provide so much freedom, and puts you in a position of power that you otherwise don't have. When you can establish the foundation financially, be profitable, and force that profit from your business. There's so much power to come from that.
You can relax to that degree and when you're relaxed about your money, it's amazing to watch what happens. The best opportunities that I see that come to practice owners is when they're relaxed about their financial condition. That's when they seem to get the best opportunities that come to them.
It seems like those opportunities find them. You don't have to go far, they'd put the word out here or there like, “I want to invest in something.” They get resources, they do some due diligence and suddenly, you're making money on top of money.
Good things happen to you.
Tell the owners what they should be thinking about with the PPP. A lot of them got funding, probably the majority of them. How should they see that money? What should they expect?The best owners are very patient with investing money but impatient with the money coming in. Click To Tweet
As you said, a lot of practice owners are around 60% to 65% back to seeing the patient that they were at. A lot of them have gotten this influx of money that is sitting in their checking accounts. The first thing is that when you get a lot of money, you have to pay attention to making sure that it doesn't get spent on the things that it shouldn't be there for. The purpose of the money is for whatever the stipulations were as part of the CARES Act and you should use it for that. At the same time, you're still seeing patients, you're still collecting money and I would be aggressive on my collections line. I would be making sure that when I'm bringing people back, especially in that area, we're collecting money and pushing production back up to the numbers that we need to get to.
You’re saying don’t be compassionate when it comes to copays and deductibles. We need to draw a hard line.
Let's not be complacent. Let's try to break all these bad habits that we had with money in the past. You got to be aggressive on your collections. The best owners that we both seen are impatient with production and not seeing a lot of money come in. They're patient with investing money and being diligent with investing money, but you want to be impatient on money coming in. I would spend a lot of time making sure I was collecting money and then I would make sure that you are controlling that money and you're stacking Benjamins at this point because I don't know what's going to happen in the future. We could get another wave of uncertainty. I don't think the people are going to tolerate another shutdown, but people are still nervous and scared and they may not show up. I would have a lot more in liquidity than what people have told you that you need in the past. For me, it's important that you have that liquidity. I would stack as much money as I possibly can.
If they didn't have it before, people recognize the importance of having a line of credit available to them at any given time. Would you recommend that having a line of credit open and available to you?
I'm always going to recommend that you have lines of credit open for everyone. I would even look at it a little differently. There are five important accounts that every practice owner should have going forward. The level of financial unpreparedness is evident. A lot of practices couldn't survive for more than one month without making any money. That was an economic reality for many practices. There's an engineering term called having a factor of safety. If you're going to cross a bridge and it says, “This bridge can only hold 5,000 pounds,” the engineers didn't build it so that if the car weighs 5,001, then the whole thing is going to come crashing down. They build that factor of safety. As an owner, you’ve got to have that same mindset when it comes to running your household finances or your business finances. You have to have buffers in place. For us, I'm trying to tell a lot of practice owners, “You’ve got to control money differently than what you did in the past.” There are five different accounts that I would set up and make sure that they're part of what my make or break number would be for my business.
Do you literally have five separate accounts?
Yes. I can dive deep into that and quickly explain each one of them. The first one, we call our wealth storage account. That's where the first 10% of your practice revenue transfers from the business to a personal wealth-building plan so that you can create other income streams for your household. That is what we call your owner pay. That is the reward that you get for the risk that you took in putting that business there having to deal with all the employee issues, the debt payments, and the compliance aspect of it. That's your owner pay so we call that the wealth storage account. That would be account number one.
Ten percent gross revenues off to the side down.
Right off the top, like you didn't make it.
I told you before if I had done that from the beginning, my financial situation would be significantly better.
It would be good. If you can at least get that one in, you're going to win the game. The second one would be a business protection and liability fund. What's the purpose of this? We all realized that we did not have enough in business reserves to pay our expenses for more than a month. I would start siphoning off money into that account. That's for the purpose of creating about three months of business reserves.
When you say business reserves, would you get that number from your CPA of your fixed expenses only?
You can make it like payroll, rent, utilities and those kinds of things.
A skeleton crew with grants and that kind of stuff. It's not your entire gross expenses. It may scale back a little bit, but multiply that by three.
It may not include all your profits and everything like that, but it would certainly be a number so that the organization can function for at least three months. Not only that, but that money would be there if you ever got sued for some reason. That would be to settle a lawsuit for legal fees. Anything that has to do with the protection of the business. We all realize that big corporations have these kinds of accounts. If they get attacked, they have resources to defend themselves.
Most of our professional liability plans cover us for $1 million to $3 million, depending on our plan but the out of pocket expenses usually somewhere around $10,000. You’ve got to make sure you have that.
It's like weather-related. Sometimes, you have a snow day and you can't see patients. You still got to pay the bills. It's an important fund to have for the protection of the business. The third one was simple. It's a tax account. In any business, most of the businesses that we see are S Corp, partnerships, or LLC’s taxes S Corp. The profits flow through to the owners. You're liable for the tax on the profits of the business personally. It would make sense to work with your CPA, get some a projection of what you think your estimates are going to be, and make sure money is being siphoned in that account. Nobody likes to get a call from their accountant that says, “You owe $50,000.” You’re like, “I don't know where I'm going to pay the money from.”
I've been there a couple of times. I had to learn the hard way. A couple of times, I had to get hit over the head. It's April and my CPA was in a great mood. He was like, “You had an awesome year last year. You made a ton of money. You did great. Do you think you're going to do the same next year?” I'm like, “Yes, I'm going to kill it.” He’s like, “Make sure you put a check in the mail for $80,000 for the IRS because it's April 14th.” I’m like, “What?” I had to figure that out quickly. Setting money aside is important too.
You want to set money aside for that. At the same time when you start making a lot of money, you're going to want to invest or utilize that money to create tax structures where you can minimize your overall tax liability. You need money to do that. They set up structures so that they can utilize them to offset their taxes.
When you say other structures, you're talking about other LLCs that cover your family, toys and cars?Practice owners are overachievers. If you don't have a target, you are doing yourself a disservice. Click To Tweet
Yes, or other advanced tax structures like conservation easements or captive insurance companies, things that you can create, but you need money to do that. That can help offset. You can either pay that or the IRS, you choose. I'd rather do that one right there. The fourth account is simply going to be a business expansion account. How I try to look at this is there's this idea that you have to use debt to expand. You can use debt to expand, but I don't think it's always necessary to have to use it. In business, you should be able to have enough profit where you can reinvest some of the profits to use for expansion, either buying more equipment, buying satellite practice or putting 20% down on a new building or something like that. The idea that I always have to use debt to expand, I don't think is necessarily true. I would have some business expansion funds that you use to facilitate the growth and expansion of your business.
Especially as physical therapists, when we expand like that, that usually entails hiring on a physical therapist which is going to require some upfront salary before you get a return on that investment. Whether it's a new PT that you've got to bring on or tenant improvements that you need to do the space to build a bigger building. They want the cash upfront for that and the bank is going to ask you to put some cash down in these situations, have some available and ready for you. That way, the opportunities before you with so much cash and reserves specifically for business development make it that much easier.
Let's say that you did borrow a bunch of money to expand a bunch of practices and all of a sudden, they shut down the economy. You then have no money coming in and you have all this debt service to pay. It's another reason why I have a mindset that I don't necessarily need to always borrow to expand. It doesn't mean that you don't borrow money because borrowing money for expansion or cashflow producing assets is warranted but not necessarily all the time, especially for a PT practice. The last account, my favorite account, and I came up with this, so this is mine. It's called a celebration account. A lot of practice owners wildly don't celebrate their victories as much as they should. It's a grind sometimes and you need to celebrate to get off that mental charge that accumulates with that grind. I have people siphoned out. It doesn't have to be much, it can be $1,000 a month or something like that. It’s like, “If you hit the goal, I got this $10,000, $12,000, $20,000 and I'm going to blow and have a celebration of some kind.” It's important to have something like that as well.
Life is all about the experiences. If you want more cool experiences that you can generate, how rich is your life? The cool thing I like about all of these is I've done this to a certain extent myself. It makes it so easy if you have automatic transfers. I have my tax account and I know how much my taxes should be at the end of the year whether it's property taxes or personal taxes, we can estimate and whatnot. I have an automatic draw from the business account into that account. Same thing with my Business Protection Liability. I siphoned off a little bit of money so I never have to think about it. You set it up one time and it siphons money off every month. The money was never there, to begin with. It's not like you're writing a check and grimacing at the same time.
A lot of practices have an opportunity to set these accounts up. You want to set it up automatically and systematically doing this. What it does is it puts an expense on the business and that expense needs to be covered by demand of income. That's why it works. That's the only reason why it works because the business now gets accustomed to it as an expense style. I would start small and then build up over time in doing that but if you can get most of these accounts in as expenses, then you are never going to have to worry about turbulent financial times because everything is covered. That's how it should be. That should be normal. It shouldn’t be, “I have to borrow $150,000 or $200,000 from the government to save my bacon.” I don't think anybody wants to get in the habit of doing that because it makes people not be responsible necessarily for their money condition if there's no way you can lose.
Let's take this as an opportunity as the lesson learned. Hopefully, for most of the people out there that are reading, they weren't completely devastated. They have an opportunity as they're building back up that they can establish these different accounts and set up for their future. The Wealth Storage Concept that I had Christopher Music on, one of my first episodes in 2018. By the way, we had our anniversary here, the first part of June 2020 with a contest. He mentioned 10% off the top and that blew my mind crazy. Since I’ve read about it with Mike Michalowicz in Profit First, and he has a great way of laying it out and whatnot. Even if it's not 10%, to begin with, how easy would it be to start with 1% or 2% of your gross revenues, siphoned off and then increase by a single percentage point every month or two until you get the time? You can either rip off the Band-Aid and go straight to 10%, or you could gradually build up if that’s going to be a little bit hard for you.
I wouldn't encourage that. I would start with like you said, a flat dollar amount and then automatically program it up over a 10 to 12-month period until you get up to your 10%. It gets the business accustomed to that as an actual expense. That's the best way that I've seen it done but it works either way. All of a sudden, you’ve got a couple hundred thousand dollars sitting in your wealth storage account, your business accounts are looking healthy and you feel like you're in control of your money.
It puts you in a position of power because the last thing you want to be is in the same situation that you were, especially if you got negatively affected by the pandemic. You don't want to be in that position with so much going on around us, so much unrest and many questions about the future.
Not me, not at all. Think about how people are feeling now. You almost felt like a dartboard like everything was happening to you. Unfortunately, a lot of that has to do with how the system is set up and a lot of business owners feel that way. They're under a monetary system where your money is not worth anywhere near it was years ago because of inflation and they're putting more money now. You're under a political system where you're like, “I have no idea who to trust. I don't believe either party. I don't believe anything that they're saying.” We were under a tax system that's completely ambiguous and hard to understand. You're under a healthcare system.
I don't have to tell PTs about the healthcare system. You're under a legal system where the rights of you as an owner are underneath the rates of employees or anybody that would want to target you for your money. You're under an investment system where you put all of your money in the stock market. We'll hope and pray that everything will turn out even though I don't have much control over that. I can understand why practice owners are spinning around sometimes but there is a way to fight back. The first thing is that you have to take the viewpoint that I can do something about each of those and then get a plan together on how you're going to fight back because what's the alternative?
It's not hard. That's the thing. There are not a lot of mental gymnastics going on here. You have to open up a few bank accounts and spend an hour or two setting up transfers. Over time, there’s a lot of comfort in knowing that everything is managed financially.
All of those things I mentioned can be done in such a short period of time. The actions that you would need to create in order to change your financial trajectory. People think it's going to be this long and arduous process and it's going to be like, “I'm going to have to change my lifestyle and all that.” You do a little bit but at the end of the day, isn't it worth it to pay the price for the next 2 to 5 years to have the rest of your life where you never have to worry about money again? To me, that's worth whatever uncomfort you'd have to do in the short-term to put in the systems in place so that your household and your business can flourish over the course of the next 30 to 40 years. Don't be shortsighted about things. Don't fall in the trap of, “I always have to have the nicest car or the most expensive house.” You can do all those things but you have to follow good financial habits and pay a little price in the beginning.
I want to touch on quickly that came to me. It was something that an exercise that we went through in your three-day Financial Freedom Summit that you have done. It was simply an exercise that you took. The group of us, but it was me and my wife, sitting down and determining what our monthly revenue goal was as a household. I wonder if that's appropriate for people to consider because you did a previous webinar about readjusting your 2020 goals for your clinic. It's a good time to consider our financial goals for our household. If you haven't gone through the exercise before, figure out what is that monthly goal that you have in revenue that comes from your clinics to your home? We set a number that is that's high for us. At that time, we're like, “I don't know if that could happen.” That's our number. It's not just meeting our expenses, it was double of what we assumed our expenses would be. It was crazy which would make us living high on the hog if we can get to that but it's getting close.
I'm telling you, if you don't have a target, you are doing yourself a disservice. Practice owners are overachievers. They love to achieve targets. This is the problem I have when people are working with financial advisors. I asked them, I was like, “Did they give you an actual income target for your household? How much money do you need to make? That doesn't consist of what's going to cover to pay your ‘expenses.’ That would include you putting money away into investments to create other income streams that would include your taxes and the other goals that you have. How much do you need to make to live the life that you want to live?” It is unlimited. Once you get that number and you see it, it's not a confusion. It's a certainty point. All you have to do is say, “I thought it was $200,000 a year, but it turns out that I need to make $400,000 a year. How am I going to do this?”
The good news is you have a business. How much would I need to get this business up to where I could earn $400,000 a year for my household? You operate on that target. By doing that, it's amazing what happens. Year-after-year, client after client, when I give them targets, I look back and I show them like, “Remember when we gave you that target?” I look back, “How much have you made?” They're like, “I didn't think about that.” I'm not taking credit for it but it's part of giving the observation of things and giving someone some reality that, “This is what you need to do.” It increases your necessity level, financial awareness, and demand for money. That's the secret sauce there because all I do is show people how to channel it, control it and hopefully expand it but it's your job to go out and make it.
It's a cool exercise. The coaching clients that I have, I'll say, “What are your financial goals with regards to the clinic?” “I want to pull $200,000 a year from that clinic.” I'll say, “What does that mean? What profit margins are you running at? How many visits does that entail? Are you working full-time or part-time or not at all?” That stumps them. They want to get to the number. Working backward and figuring out it's not a number, it's an ideal scene that you want to get to. Let's get clear about that. Once we have some clarity about that and what your part is in that ideal scene, let's work back into the numbers and see where the gap is between where you are now and what you want to be at because you'll then recognize that, “I'm only seeing eight new patients a week. I need to bump that up to twenty.” “What are your marketing efforts going to take to get from eight new patients a week to twenty new patients a week?” That starts giving you some action items but if you have some clarity about that number, there's something magical about putting that intention out in the universe.
You hit it right on the head that the clearer you are precisely what you need or what you want your scene to look like, the better you can compare it to where you are now and you can see what the outpoints are. For a lot of people, the gap isn't that much. It doesn't take a lot to bridge that gap but you need a plan. You need someone to hold you accountable to making sure that you're hitting those numbers as well. That's an important part.
That's huge whether it's a financial planner. Honestly, a lot of the financial planners that I have had in the past aren't good at communicating in those aspects. Finding the right financial planner and a coach that can walk you through that thing is important. They make you verbalize and hold you accountable like you're talking about. That's a huge part of the process. Another success story. One of my first guests was Sean Miller. He sold his practices at the same time we did, but five years earlier, he said he had a number in mind that was like, “I want to get to this number as far as wealth. I want many thousands or millions,” whatever that number was for him. Five years later, he hit it and there's something to it. We're talking about action steps and that stuff but sometimes it's simply the intention is out there, you visualize it, you have that number and you keep that number in your head.
It's a decision that you make. You look at the derivation of the word decision. It means to cut off. When you make a decision that you made, you cut off anything else that would prevent you from reaching whatever that is. There's some power behind that. I can't explain a lot of things but you can observe the phenomenon and know that it's true because you observe it.
Once you make that decision or things, that tend to fall in place.It's important that you get a plan, get some direction, and be very precise on what you're trying to achieve. Click To Tweet
As long as there's a good purpose there. Another thing too, you keep your ethics in good shape and that to me is a secret for success because if you're doing the right things, there seems to be a reward for that. People that are doing immoral, destructive actions, there is a penalty to pay on that one. That's a whole other webinar.
I did another episode with Mike Bills. It was simply not so much that he was doing anything immoral, but he put more emphasis on improving himself. As he did that, as he focused on himself making his time sacred and holding other people accountable around him, his business tripled in about eighteen months.
It can happen so fast.
It can happen quickly. There's some power to maintain your ethics and don't sleep until 10:00 AM. You're not going to get to your number by that, but to maintain your ethics, hold that number fast and steady. As you said, the clinic owners we're overachievers, we'll get there. We'll find a way.
We always do. I love it.
Thanks for coming on. Any parting shots? Anything coming up with the Econologics that you want to share?
I would say to your readers, we're offering 15 to 30-minute free consultation. If they want to contact us, then they can certainly meet with one of our specialists and we'll cover any questions that they have from a financial aspect. I would not wait. I would not pause and contemplate what I'm going to do with my money. Now, it's important that you get a plan, get some direction and be very precise on exactly what it is that you're trying to achieve because the dangers of not doing something like that are too great. There is going to be a different financial scene in this country in the next years.
The people that know how to produce, manage their money, control their money, invest it correctly and stay out of debt, all those things that we show people how to do are going to be rewarded for that. The people that are saying everything is going to go back to normal, I'll do the things that I did in the past. You're going to get punished at some point in time because it goes against natural law. My call to action is to get on a plan, get with someone that can hold you accountable for your actions and you can reach out to us. I'll give you a link or something like that, that they can schedule a 15 to 30-minute time with us to talk.
Go ahead and share that with us. What is that? How can we get in touch with you?
You can always go to EconologicsFinancialAdvisors.com and reach out to us that way. We've got a YouTube Channel as well, Econologics Financial Advisors. That will be a couple of ways you can get ahold of us.
You have some great webinars coming out every so often. The next one is Seven Tax Saving Strategies and stuff like that.
We're going to talk about taxes. I do want to mention that too because a lot of people that have gotten all this money from the PPP loan that they're hoping to get forgiven and it may, but at the same time, you're also building up all this cash from the money that you're not spending now. You’ve got to be a little cognizant of how much you're going to have to pay in taxes. I would tune into that. We'll give you four fairly simple, powerful strategies that nobody is using. I'm going to give you two advanced tax strategies that can minimize your taxes by $20,000 to $50,000. It's worth tuning into that and then we're going to talk a little self-storage and real estate investments. We're going to put out a lot of good webinars.
Hopefully, people stay in touch and stay in tune with what you're putting out because you've got some great content.
Thanks for coming on.
Eric 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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