It's been two years since the start of the Physical Therapy Owners Club! Hard to believe the podcast has been around over two years and 100 plus episodes. The PTO Club has generated some great content for and from PT's across the globe and is a dream come true. In this episode, Nathan Shields and Will Humphreys, Nathan's business partner, spend some time reflecting on the beginnings of their ownership journey and some of the faults, triumphs, and relationships along the way. Follow along in this special conversation, reminding you of how your journey may not be that lonely after all.
I've got a frequent flyer guest. One of my good friends, Will Humphreys, is in the house. Will, thanks for coming on.
Thank you. I appreciate it. I love being in the house.
Thanks for joining me. I had you on before and we're still surviving through the pandemic. PT owners are starting to ramp up a little bit. Some places might still be closed. I don't know if they're getting the 50%, 60%, 70% range in productivity and whatnot. Last time we talked about what people can do while things are shut down or slowed significantly. We're going to talk about a number of different things. We're going to go back in history a little bit. First of, what have you been doing since we last spoke?
It's interesting because as I went to Europe for six months with my family. I came back to Empower Physical Therapy, our company that we love and cherish. Gratefully, they were at a point where things were going pretty well. I started having some ideas of how I could better serve the industry. They've been incredibly supportive over there helping me go out and do other things. What I've done in the last few months are a couple of things I'm excited about. One of them is like a dream. Something I've been wanting to do for many years and I'm actually doing it. One of them is that I started an insurance billing company. It's called In The Black.
You were getting things going at that point.
It's been crazy because I came back with a different proposition than what's out there for billing companies. There are a couple of good companies out there that I love that are PT-owned, but none of them address all of the different influences that impact our profits and finances. We're a full RCM business, which means that we don't just do billing and collecting. We also do insurance verification. We do provider credentialing. I also provide training to front office and back office as part of that. There's no additional fee to that. It's been fun because we look at all the items, including P&Ls and what shape of company. When I was a PT, I used to think that an outsourced PT comp billing company was the worst way to go.
We had some bad experiences. You know how they do it wrong.
The biggest thing is when I did end up having what you and I created, it was your hire that led to this in-house solution that was massive. It was unreal and ultimately, it was the biggest reason why when we came together and merged, our company did so well. I wanted to share that message because I believe profitability unlocks possibility. You and I didn't know how freedom felt until we were able to get the profits to help generate that. When I did that, that's when we looked at Alaska and that's when we looked at all these things. In The Black, the website is coming out. We stopped taking new customers for the next two months because we had such high demand when we've opened. We're satisfying our first twenty locations. They're loving it, which makes me happy. We try and keep close relationships, which is different. It's been going great. We will be taking new customers for any potential audience in a few months.
For those who are reading, your website should be around August 1, 2020. You'll be taking more customers at that point. I don't want to disparage outsource billing, but because of our experiences, you know what people should truly experience from their billing company, whether it is in-house or outsourced. I talk with my coaching clients all the time about the statistics they need to be looking for and the reports they should be receiving from their biller because many of them are like, “I don't even know how to judge if they're good.” That's where we were many times until our biller showed us proper reports and statistics, we didn't know if they were good either. As we got that experience, we started seeing how billing should be managed. Coming from that point of view, you can provide a service that lacks out there in the PT industry.
I appreciate that and I do want to acknowledge, there are a couple of companies that are doing it well. I'm a big fan of MEG. I love those guys. I think they're great. Bob's company, billing solutions. There's another company that's fantastic. We were all offering a little something different, but we're all PT-owned. That's the thing is that as PT-owned billing companies, we offer so much more of that relatable advice, experience, and knowledge. That’s been going great and the thing I’m super excited about as well is I have launched a YouTube channel. You know better than anyone how I need attention. I don't know if my parents didn't pay attention to me growing up, but something feels whole when I'm filming a video.
The cool thing is your YouTube channel isn't specific to PT owners but also PT students, which is cool because there's no one out there speaking to PT students. It is pretty interesting that you would take that tag. You share some awesome input and have some great content for PT owners as well. I love the stuff that you're doing right now in regard to C-players and how to find them and handle them. That's great.
It means a lot to me. You were such an inspiration to even do it with this show. It's one thing to have the time and desire to want to put yourself out there in that way, especially when you've been through hell and back 4 or 5 times. You want to share those experiences with your colleagues and ultimately like you, this show, my YouTube channel is a love letter to my industry. It's given me everything that I have. I'm still this incredibly passionate PT who thinks there's no better job in the world. Everything that you and I invested in with coaches and clients and all these things that we've done over the years. I'm getting that information on Tuesdays. At this point, it might shift but Tuesday is centered towards leaders and owners, Thursdays is for students and new grads. It's things like, how do you stand out in job interviews? How do you find a job in the COVID environment? The seven mistakes in most interviews for PT owners is all talking about all the stuff that we've been through and learn from. It's been a lot of fun. We've had a lot of initial success out of the gate. That's a perfect way to say that guys like you paved the way. When you launched your show, there was a handful of shows.
When I first started, there were maybe 2 or 3 that stood out. The reason I wanted to do the show was simply because there was no one speaking to the business aspect. I liked Paul Gough's stuff. He focuses a little bit more on marketing and he has some great insight. His first two episodes, I was like, “This is amazing.” I know there were a couple of them out there. The PT Insiders, but a lot of them were either about marketing or about patient care. I was like, “I want more help as a leader, as an owner.” You and I had developed this amazing network of PT owners and I'm like, “We’ve got so much information out of just picking their brains.” We'd go to these conferences and you might learn something from a presenter here and there, but it was the in-between sessions and the dinners where you sit down with successful PT owners like Coury and Buehler in California or John and Chad out in San Antonio or Blaine up in Montana. I was like, “Why can't there be a platform for those guys to share those successful actions?” I thought this show is a great way to do that and it's been so cool. We were on our 100th-plus episode as of this one.I'm proud of the content that Physical Therapy Owners Club has generated over the past two years and hope it's a resource for many PT owners going forward. – Nathan Shields Click To Tweet
You're stealing the wind out of myself. I want to announce to the world that this is your second-year anniversary and you've broken 100 shows. It’s amazing. It's another thing to even stay with it for two years. I love that you mentioned some of those. It’s a big thing I want to acknowledge and I hope all the audiences at home or in their car are grateful for guys like you who are standing out, who are building upon the efforts of others to find additional ways to create value. No one is doing it the way that you're doing it and definitely with this kind of consistency, that builds trust. I love how you mentioned the heroes of our networks before and you mentioned some of them by name. When you said those names, I felt chills. I remember what it was as freshmen in high school and there were the seniors. It was like, “These guys are so cool.” Who else would you say are some of your PT heroes?
Who's not a fan of Vinod? He was one of my first episodes. Here's a guy who's got a killer business in New York City but lives full-time in Florida. Who doesn't want to live that dream? I knew Blaine was super successful in Montana, but then I went to Whitefish, Montana, I was like, “This is a cool place and this is where I would love to live.” Blaine was amazing. Those guys are great. I love hanging out with them, and then Bill out in Detroit with HQPT. He's unassuming and then he tells you he's got 15, 16, 18 clinics. He's just walking around in shorts and a tee-shirt.
I’m sure he has a six-pack. He's got zero body fat and if I ever get to the point where I can see my abs, you will not be talking to me with my shirt on.
I loved these guys and they're so willing to talk to you. We were nervous talking to these guys and we feel like the underlings, but they're totally open. They're like, “This is what we do and this is what we'll share and they do presentations,” and you're like, “You guys are killing it. I wish I could be like you.” I still feel that way. They still have so much to offer and that's why I think I'll continue with the show. There have been a number of times over the last few years where I turned to my wife. I'm like, “I need to pay for more production of my episodes.” I don't do all the editing and whatnot myself. “I have to pay some more upfront. Should I do it? I don't know. Maybe it's run its course.” Every so often, I'd get this jolt and I had an amazing interview with somebody that I think is full of awesome content and I'm like, “The PT world needs to hear more of this.” I guess I'll keep going.
I want to challenge everyone reading to comment if you're able to get on iTunes and give some love because what you've done for the industry has been massive. It’s great because we met these guys through a group called Measurable Solutions, which still exists and still has amazing powerful PTs, Mike Bills. The main thing that they presented besides wonderful information was each other and that's what you're doing. You're connecting our industry. As a guy or girl is reading, they're feeling like they're a part of something so much bigger than themselves, which is why we got into this whole career in the first place. Not a single PT I've met in all of the years of talking to PTs has ever had a boring story. Even when they think it's boring, there's this huge emotional draw. As a two-year anniversary highlight, I'd like to ask a few questions about things I don't even know. You mentioned that you did it because you felt like you wanted to create more value. Emotionally, what was some of the first experiences you had? What were some of the challenges? What were some of the initial wins that you had?
With the show or with PT ownership specifically?
The show, let's go into that. I'm sure your audiences would love to hear about some of those experiences in the company as well.
I remember my first episode and I was interviewing Sean Miller, our good friend and partner. I knew he had a great story and so I wanted to share his story. I remember walking through my house an hour beforehand and nervous telling my wife, “forty-five more minutes and I’ve got to do my interview.” I’ve got to sit down and just shoot the bull with Sean. He's still one of the most listened to episode. It was awesome and I came away with that energized more than anything else I'd done before. Physical therapy is very fulfilling. I rarely came away from a treatment session where I was like, “That was amazing. That was fun.” Even if I did that, there was some crappy patient right after that would spoil my day. I'm sure you experienced that. By the end of the day, you'd seen enough patients that you're drained mentally. After doing my interviews, that carries over to my coaching stuff. After doing my coaching client stuff, I can sit on the phone with owners for an hour and a half, two hours and be like, “That was cool.” My wife tells me all the time when I came out of the interviews or I come out of my coaching client calls, I'm like, “What's up? What's happening? The sky is blue and the birds are chirping. Did you guys notice?”
It's cool because number one, I'm curious. I want to know what's making people tick. Number two, I can come out of those interviews and be like, “There was some cool content out there that if the people out there listened and pulled away 1 or 2 things that could help their business.” Number three, helping people simply feel connected so that they're not alone. That's where I felt so much when I started my clinic. You probably as well since you're out in the boonies of Florence. You feel like you're on an island. You're on your own. Who else knows that I'm even out here besides my “competition” within a few miles of me. It wasn't until I started networking and getting consulting that I recognized I'm not alone. There's a whole bunch of people that have already been there, done that and they're willing to help. That's what I wanted to provide owners. There are people out there and you can reach out to them. Almost every episode, they share their contact information. You can reach out to them. It’s hardly anyone takes them up on it, but they can. They can pick these people's brains and they're open. It's so funny to have Dimi on and he'll share his personal cell number. It’s cool and I love sharing with people. It gets me energized.
It’s neat to see you in this space. I've known you for a long time now. It's been many years. I met you in 2003 at Fat Camp. You were my sponsor. Do you remember where we met?
If I'm not mistaken, I met you at church in the hallway or something like that.
I remember meeting Whitny before meeting you. I remember she came out to me and said, “You need to work for my husband.”
She came home and said, “I found the guy that needs to work for you. I found our next PT.”
We are here because of Whitny Shields. Shout-out to the amazing mother of seven, your wife. She moves to Alaska to start electrodiagnostic company. She's an unsung hero. Tell me, what was it like for you when you were thinking about those early years? Do you have any memories? This is where I'm trying to serve your audience is trying to get them to understand a little bit more about you and what I know, and maybe what I don't know about your background. Can you think of any experiences that you had that were pivotal to your growth? You've mentioned Measurable Solutions and that wonderful network of people, which we'd be remiss if we didn't highlight Beth and Lisa out at Magnolia, Louisiana. Some of the most powerful leaders of all time. Do you have any other moments like that that you think of as pivotal in terms of, “When that happened, things changed?”
Taking the first step was huge. I still have to attribute that to Whitny because I was working full-time for a physician PT clinic for about a year and a half. I remember after work one time, I was like, “I was looking at this area in that area to maybe open up a clinic someday.” I saw a for lease sign of a new construction built down in South Chandler. I gave Whitny the phone number and she was going to call him the next morning when I went to work. She's like, “The rates there are amazing. It's a brand-new build. We've got to open up a clinic.” I was like, “We do? Is this happening?” She was like “Yeah, put in your two-week notice. Let's go.” You know me and change, we don't jive. That's why I married my wife. She's like, “Change is great.” I’m like, “Change sucks.” Finally, we opened that up. The referring physicians down there were gracious and helpful, especially Dr. Paul Evan reached out to me out of the blue and that was great.
All that was pivotal, but you had to learn so much. Back then, I was doing the billing myself. I didn't even know how to do that. I was doing the credentialing myself. I was marketing by myself. I didn't have any support staff. Occasionally, I'd ask my mom to come in and help, be attack or something like that. That was all crazy but outside of the initial beginnings. That was in 2002, pivotal parts were like you and I opening up the Maricopa clinic. That was a huge change and we thought it was going to be a lot easier than it was.
If I look back on it and I'm going to ask the question to you, what I would have done differently. What I would tell myself as a young owner, knowing what I know now, is to get some coaching or consulting in day one. Hire the people to do the work and trust the experienced and professional people to do their jobs. It will get you so much further so much faster. If I could have seen that. I didn't even know that was an option on the table. I'm running by the seat of our pants and doing what we can and saving money here and there. I thought that's what you're supposed to do, instead of investing in the company to help it grow. That's what I would have done differently and it's when I started making those investments that things significantly changed. Unfortunately, it took me close to a decade or more before we did that.
I remember the day we signed up with Measurable Solutions. We went up there for a two-day course that I paid for because I was desperate for help. I paid for 1,000 courses. Last minute, I'm like, “Do you want to come to Seattle with me?” It’s good for two people. You and I hadn't merged our companies yet. There was some separation in our business model, even though we shared Maricopa. When we went up there, it was mind-blowing. We met Steve Rodriguez who is now family to us. I don't even know how many years it was. At the end of it, they're like, “Here's how you get to freedom and here's how much it costs.” Your jaw draws open. You say you don't handle change but you were the one who was like, “I think we need to do this.”
At that point, I distinctly remember we have to do something different. I don't know what it was. It could have been like a webinar packaged for $500 and this was significantly more than that. I would have done anything to make a difference. I wasn't experiencing a life that I wanted to continue living. I told people all the time that, “I loved treating patients, but I hated the business aspect of it. If I have to continue at this pace for another ten years, I'm going to be done. I'm going to be checked out. I don't know what else I'm going to do, but I'll find a different career.” I think that happens a lot with PTs. That's a topic for another discussion. What's funny is since I got the consulting and coaching and networked with entrepreneur’s organization, I don't get the joy out of treating patients as much anymore. I love treating more patients through other people and creating a bigger impact within the community or even within my small clinic to affect the community, to make it a better experience for not just the patients, but also the team members and grow and improve that way. Now I get so much more fulfillment out of being a leader and an owner and giving back.
I don't think that's everyone's journey. The reason that was true is because you were meant to do what you're doing now. The problem with a lot of us in our industry as owners is that we get into that mindset of like, "I did this to treat and that becomes an excuse to not learn what we don't understand about business. Both of our cases, I had a pivotal moment in my life. When it occurred to me, I was driving home in the dark at the end of a horrible day. My beeper's going off because my charts weigh as much as a human being in the seat next to me. I am so burned and it occurs to me in that moment of clarity that it doesn't matter how much I know about patients and patient care and making that process go well. It would never make up for what I didn't understand about business. That's why coaches are so valuable.
I think you are meant to suffer that way because now you're supporting this mastermind, which I got a chance to be with those guys. It's like seeing all those wonderful people in our old group at our earlier stage. These powerful men who were committed to doing something better. Once they get free of the demands of what they don't know in the business end, you can always opt and choose to go back and treat electively, but not because the business requires them. That’s the difference. In your case, you got free and it was like, “I want to share this message with the world.”
What would you tell yourself as a younger owner?
I can't reiterate enough what you said about finding a coach as quickly as seemingly possible. When I came back from Europe and I'm consulting. I'm still working with Empower, but they were like, “Go ahead and have some space to do some other things.” As soon as I heard there was space, I hired a coach as quickly as I could get my hands on. My beautiful patient wife, she saw how much I put down on that. She was like, “I get it.” That's what it is. Freedom comes at a cost and it comes at a price. We probably paid multiples of our PT degree to ultimately achieve financial freedom.
It was hundreds of thousands of dollars.
That was over years but it was a small investment into what ended up creating impact, income and freedom.
My wife is the same way. I might go a few months without a coach and find one that that's aligned for my purpose and what I'm doing now. I'll tell her, “It’s many thousands of dollars,” and she's like, “Okay,” whereas that wasn't the case a decade ago. What she's recognized in me, and I know your wife’s recognized that in you, is that you having a coach improves you as a business owner and leader, but also improves you as an individual and a father. When you're talking about creating freedom and living the life you want to live, a lot of that is not necessarily about you. It's about your relationships with your significant others, your partners, your children, your friends, and whatnot. When you can improve your business to the point where it gives you the freedom, the space, the energy to share with other people, that's when your life changes.Profitability unlocks possibility. Click To Tweet
What do you think are some of the things that showed up in your personal life that are a result of you having owned a business? How are you different as a father and a husband because you had the courage to go out and start a company?
I have a better take on what it takes to lead and that leadership is not limited to the business and professional aspects. There's some leadership as a father that are necessary to lead a family and so that's important. What's helped me a lot, and maybe you can speak to this as well, is the ability to have those one-on-one conversations with my wife and children. Come at a place of objectivity out of curiosity, from a point of understanding and not from a place of judgment and learning more about myself as I go through these experiences. It makes me better as a leader. Some of those things that are related to that also include, what's my purpose? What's my individual purpose? I talked about purposes for your family here on the episode or purposes for your clinic here on the episode, but what's your individual purpose? What's your purpose for your family? What are some of the goals, just like you have goals for your company? Do you have some goals for your individual self as well?
Relating so much of that, we'd like to think that’s professional life and this is personal life, but how do you draw the line? People say, “Don't bring your personal life into the workplace.” How do you do that? Because it happens and there's no way you can flip the switch and go home and all the stresses that you felt at work, aren't going to somehow affect how you're treating your family at home. When my wife recognizes that I'm not up at 4:00 AM and coming home at 8:00 PM or 9:00 PM because I'm seeing patients and doing charts and running the business, but rather have more freedom in my schedule and more time for them. I can go on vacation without getting emergency calls every other day, wherever we're at. She's like, “Whatever coach or consultant you need, go ahead.” We'll spend a few thousand dollars to make your life a little less hairy and have our kids have a picture of you as a father.
This isn't just for physical therapists. I think PT owners probably experienced this in large amounts at least early on, but how often do we give the leftovers to the people at home after a long day at work? The hardest hitting thought is for how many years I would come home with a moderately successful clinic that was me dependent. I’m holding onto that from a place of insecurity because who am I when I'm not that? Coming home and faking it through, playing with my kids and stuff. The generations of owners now are hopefully not where I was in that regard but when you talked about that, that resonated with me is how there is no separation between these different environments. We are who we are. We are better or more successful in our environments because we're sacrificing something of ourselves at the other. My favorite analogy when you described is the idea that we're all juggling different balls in life.
There's a ball called work and a ball called church and a ball called home and family, and they're all made of different materials. The only one that's made out of glass is family. Work is as important as it is. It's a bigger ball that we're juggling but it's made out of rubber. It will drop and as painful as it's been to hear my journey but listening to you talk about those moments. What I sense is that overall, understanding of what matters most and when you learn from dropping the ball here, it's so that you don't have to drop the ball of the family, which is the most important one. Thanks for sharing. That's powerful to hear how that shaped you as a person. Do you have any memories of fun time? I don't want to paint this picture that ownership sucks. What were some of the best times professionally that you have. What are some of those moments?
A lot of it was surrounded around the patients. Sometimes you get a certain patient mix and you look forward to those afternoons because you’re all kicking it and chilling and once, I got a TV in the office. I was watching the Olympics or the Major League Baseball playoffs or something would come up on TV that would spark a conversation. Those days were awesome. Getting your first checks from insurance companies back in the day, I was like, “They paid me to do some work that I'm not even sure I know how to do well.” Worrying that they're going to figure you out someday and the auditor's going to come and say, “You're not a good therapist. Give us our money back.” Making something successful like that. We had some awesome fun company parties with people.
Acknowledgment to Stacy Sullivan. She was with me for a long time. It was sad to see her pass, but my memory still revolves around her coming in every day. She’s like, “Good morning sunshine.” My wife said that to me the other day in the morning and I was like, “That's what Stacy used to say.” It’s individual people and individual experiences that I remember more that gives me happy memories about it. It's something prideful to go back and say, “Here's something that started back in 2002 and it's been an amazing journey and changed a number of people's lives. Not only the people that I've treated, but people that I've worked with and team members that we've had through the years.” It's been a cool experience to look back on that. I can't say all that without saying, “Some of the business trips that we had were some of the coolest times ever.”
That's what comes to mind when I was thinking about this interview. We have times and some of the ones that you and I have are epic.
That was probably worth the price of admission for all the money that we spent on the consulting was to simply go to some of the conferences whether to Florida or Seattle. I feel like I know Seattle with the back of my hand.
I calculated it. We spent six weeks back-to-back there after two years.
It's Seattle all the time with the place. We go to Montana or New York City and all these cool places together. We kick it. It was so much fun. Those experiences in that time were what makes it a lot of fun to look back and say, “That was super cool.” To have the opportunity then to share those experiences with my family and now to take some of my kids to New York City or tell them, "Someday I'm going to take you to Whitefish and you're going to experience how amazing Whitefish is,” or “I’ll take my wife to Clearwater once in a while for a seminar and see the amazing white sand beaches.” That stuff was super cool.
It’s that investment is what forced us to open up to what it could look like if we weren't committed full-time to treating and running the aspects of our business that we weren't meant to. I remember multiple times, you and I would make the comment. Who'd have ever thought when we started this tiny little clinic in Florence, Arizona, that we'd be in New York on 9/11 at ground zero, or we would be in Florida on the white sand beaches, or we'd be in Seattle at the Farmer's Market or the Pike Place there? All the different things that we did. Ultimately, we were able to take some trips. We bring our spouses and, in those things, they weren't the reason why. They were these little perks that occurred to help counter some of those dark times. I feel like every difficult time at least that I experienced in that journey being with you came with comfort. It was a conversation I needed to have that I didn't know how to have.
It was usually a relationship that was out of alignment and I didn't know how to address it. I feel what you're saying around that. I want to quickly highlight for the audience that you are an amazing technician. Your skillset of physical therapy is one of the best that I've ever come across. I'm not complimenting that. Nathan and I were looking at setting up this business in Alaska and you were able to grasp the electrodiagnostic understanding, which is a totally different belt. It's not a different tool in the belt. It’s a totally different belt. You pass that exam, which is a whole other board-plus some. To prove a point, I passed a kidney stone, thanks to you. A real short story. My urologist has told me since it's the biggest kidney stone he's ever seen pass from the kidney through the ureter. It was an 8x8 kidney stone and I didn't know I had a kidney stone. I thought I hurt my back and Nathan and I would be in our business meetings and he'd be treating me. I know for a fact, that's what did it. You manipulate that kidney stone out of me.
I milked that kidney stone through your ureter.
It was an intimate moment. Your skillset is phenomenal. When I hear you talk and you're like, “I don't know what I was doing,” I want to make sure people knew that you were a master at your craft.
I had this vision initially set up that I was going to open up my own clinic, but because of the work I had done in Casa Grande, you guys don't have to know the geography of Arizona, but I was working in Casa Grande. I started a clinic in Chandler. I always knew that I wanted to open up a clinic in Florence. That was at the back of my head always and I don't know why I was thinking, "I’ve got to go to Florence.” I opened up a clinic in Florence, bought the equipment, and found the space. I didn't have a single provider in hand. We met you and Whitny is like, “This guy’s got to work for us.” I'm like, “Who's going to want to work in Florence?” You remember the space that we worked in. I showed you the equipment that I had in my garage. I was like, “I'm taking this down to Florence on Tuesday. Do you want to come with me?” Somehow we set up a way to get down to Florence. I was nervous that you were going to see Florence, Arizona and be like, “Why am I working here?” It was the complete opposite. You have to share with us your experience.
It was fun because you've got more years ahead of me than I do and so in terms of experience in PT. It didn't matter that you were only two years of piano lessons ahead of me. To me, you were a grand piano master. We're driving out there and it's 45 minutes from our house and it's getting close to an hour or whatever. We pull into this tiny little town and all you see on the outskirts are jails and prisons. I think the actual number is eighteen. They have eighteen different facilities ranging from high security, maximum, whatever and you pulled me up at this building that was probably 100 years old. It was 600 or 800 square-feet total. It was musky and infested with lizards.
I remember we had termite tunnels hanging from the ceiling.
I'll never forget, you walked me around and there's a big safe, because it used to be a bank back in the ‘40s or ‘50s. We got to the car and you're like, “What do you think? Do you want to work for me?” I'm like, “We haven't talked money.” You showed me this decrypted building but I was like, “I'm optimistic.” Growing up in El Paso, Texas, it gave me this point of reference of community feel. It felt like when it ended up becoming this unbelievable experience being out with some of the most kindhearted family-oriented human beings I've ever known. They were still, to this day, the one population that I believe for more than any other is the people in Florence. They are as kind and generous as they are and anything else, but it doesn't look like that when you're driving through it. When you're driving through it, you're like, “What was that?” I remember thinking like, “He's new at this, I think.”
“He doesn't know what he's doing.” You're dead on.
You're great to work with. You're always easy going you. The reason we were able to succeed all these years was because we laughed at things. Our relationship would have caught in a different direction if we didn't have so much in common over stand-up comedy. He introduced me to Dane Cook when he was okay to listen to. I’m like, “Who is this guy?” He introduced me to Arrested Development. That was a big thing. Tell everybody what the name of our company is that we created. The one LLC. There are two actually. The Hermano Holdings and we have banana stand. That’s one business that failed.
There's always money in the banana stand and Hermano still exists.
I want to highlight some statistics that I wish I'd done right out of the gate. For two years in, you're over 100 episodes in. You are at 35,000 listens that blows my mind. As you look forward for the show, your coaching and your masterminds, what do you see for yourself?
It's hard for me to see that. I'm not necessarily visionary in that regard. My vision is limited a little bit forward so I can see some steps and moving that direction. If I like it, then I'll continue going down that path. The mastermind has been cool and fulfilling. We've had one meeting, but I love these guys and it's exciting to see the banter and the collaboration between them. The coaching, I’ll continue to do that. I enjoy that. Sometime, maybe it will run its course, but I'm enjoying it a lot right now. The show, I'll continue doing it. Sometimes, it's hard to find guests. I come back to guys who I know are solid like you. I interviewed Eric Miller. I'll have some featured guests every so often that are the same dudes, but they do great stuff, and have a ton to share. I'll keep doing the show because I find it fulfilling. At the end of the day, if I did stop, I'd be comfortable with it because we've put some awesome content out there and it's out there in perpetuity. My kids, grandkids, great grandkids can always hear my voice. I think that's cool and I'm able to share some of the things that I believe were successful, not just about business ownership but about life. Where does this all go? I don't know. We're loving Alaska right now and enjoying it. I look forward to doing more and serving more, and helping PT owners out there. That's where my head is now.
I have something I'd like to ask for you to do as a final thing if you're cool with it. It's a little bit different. If it aligns for you, do it. If you want to wrap it up, that would be great. It all comes back to family, that glass ball. You mentioned at the very beginning of this episode that’s the real reason why we're doing all this as we help patients and as we have the courage to fail over and over again as business owners. It ultimately shapes us as leaders in our home to help us make an impact where it matters most with those little children who are growing up. What would you like to say knowing that 100 years from now, your great grandkids are listening to this? What would you like to tell them about what matters to Nathan Shields?
That's where I tend to get spiritual. I believe in God, Jesus Christ is my savior. A lot of it has to do with faith. I go throughout the day constantly thinking and in my mind praying, maybe not on my knees, but I’m praying like, “What do I do next?” I’ve got a list of to-do things here. What's the highest priority. Am I missing something? I'm going to start at the thing that's easiest for me that I think is the highest priority. Inevitably a thought comes to my mind, “You need to consider your wife.” I hadn't thought about that. When the kid is having some issues. What do I need to say to him? It's either an inspiration to like, "Go talk to him now," or “He's going to be okay. Spend a little bit more time with him this week.” That's where I have to be grateful for the influence of our kind Heavenly Father to give me those inspirations to lead my family. That's where I can look back many times where I see His hand in my life that I'd be remiss to not be grateful that that's there.Creating freedom to live the life you want to live is not necessarily about you. It's about your relationships with other people. Click To Tweet
I've spoken to you about it when we've talked about business decisions that simply either I feel good about it or I don't based on the prayers that I've had and the answers that I feel I've received. My wife and I talked about it all the time, “How great is this? How cool is this?” This isn't a conversation that we have now that we've reached the pinnacle type of conversation. It's been like that throughout our lives. “How cool is it that we witnessed this happen over the past 6 to 12 months? What would have happened if we hadn't been inspired to do that? How well did that turn out for us?” We're talking about things that you otherwise maybe don't pray about. I had an inspiration to sell our house in Chandler and it was not at buyer's market or a seller's market. I talked to my wife about it. She felt good about it and got the house ready in seven days. We put it on the market and got a full price offer in 24 hours. It’s not in a sellers’ market. The realtor was like, “This doesn't happen right now in this market.”
That's a witness to me that number one, He exists and number two, that His hands works in mysterious ways. A lot of it's about faith. A lot of it is Whitny, my wife, the huge support that she is. I think a lot of owners are like that. There's somebody in their life, whether it's a spouse, a parent, family friend or a mentor of some kind that they have to lean on and that helps a ton. You have that someone who's in your corner no matter what. Giving you the push and the inspiration to live outside of your box and make you a little uncomfortable and force you to sacrifice things and things that you otherwise wouldn't sacrifice. A lot of it goes to Whitny and maintaining that relationship and it's those relationships. You would agree with me. The relationships that we've developed over this time are powerful, emotional, fulfilling, bringing not just happiness, but joy.
The people that we've been able to work together with. My relationship with you is super powerful, loving, caring and supportive. You're my biggest cheerleader outside of my wife and family. Even down to Stacy Sullivan, Michelle, Erica and Katie. These people and these relationships that we have with people are so fulfilling and amazing. Even the people who came in and out of our lives, past employees that no longer work for us or whatnot. I still love and I enjoy them and it's those relationships. I think about patients. The physical therapy profession is such a cool experience that affect many people's lives positively and develop relationships in short amounts of time.
It’s a cool opportunity. You get that with your patients. You get the same thing with your team members, especially your leadership team who buys into your vision and has faith in you. You're like, “Why do you have faith in me?” I remember asking Stacy that all the time, “Why do you still work for me? I know you hate what I do.” They have faith and they captured a vision that was probably granted than our own, which is weird. I then develop relationship with you and then we talked about our network, those relationships. If those guys reach out to me, like Vinod texted me, I felt a teenage fangirl. It’s like, “Vinod texted me. Mom, Vinod wants to talk.” That kind of stuff and to meet Dimi and Shaun Kirk, and the benefits of the show.
I've had opportunity to talk to Heidi Jannenga and some of the huge leaders in our industry that have been around for years and years. Randy Roesch and, Greg Todd, and Jerry Henderson from Clinicient and all these cool people that I never would have been able to meet before. I've had an opportunity to develop some awesome relationships, but it all comes back to I feel like I'm living right. I've got my ethics in order. I rely on my Heavenly Father and Savior Jesus Christ to guide me on a daily basis and try to do what's right and it's that simple. That's what I hope my kids would remember. I hope my kids remember that it's not that hard. Your life's going to suck at times. We went through the experiences, but we came away with wisdom and knowledge, an ability to empathize with other people who go through the same thing and say, “You have bent there? Do you want to know what you can do about it?”
Help them in that regard and not just PT owners but with our kids, with our spouses, you can have the same empathy when you go through crap like that. We're not at a point yet where our kids are married. Heaven forbid our kids get married and now have to deal with spouses of their own. They're going to be like, “I had that argument ten times over with my wife.” There we go. They then have kids of their own. They're like, “Dad, what are we going to do?” It's because we went through some of those crappy trials along the way that helped us learn and gain wisdom and humility. That's some of the stuff that I'll always be grateful for. It has been a cool experience in that regard.
Thanks for that answer. On behalf of everyone reading, thank you for being who you are, for creating the show. I love and adore you. It's a treat to be in your life and I'm grateful for the example you said. Not just in the show, but who you were beforehand and your continual application to be a better human is inspiring. I wish people in the audience could know you the way that I do and ultimately, they get teary a little bit. Thank goodness for the PT Owners Podcast.
Thanks for joining me. It was great to sit and shoot the ball with you and reminisce. I was nervous about how this would go because I've always been the one to highlight the guest and I rarely liked to take the spotlight. I didn't know how that was going to go. It's been awesome to think about it.
It’s my favorite show so far for me.
That's cool because you're the one that wants attention. What you didn't say is how do people get in touch with you. When you're ready to take on more clients because you guys are killing it, how do people get in touch with you?
What we'll do for anybody who's interested is if you're not sure about your existing billing solution in the last couple of months, one of the reasons we've been successful is I don't have to grow this thing. I want it to be a major influence in the industry, but I don't have to grow this billing company out of a need to. What we ultimately care about is making sure you get what you need. I've told people that they should stay with their in-house solution. I've told multiple people that. I told other people that they should outsource, but I'm not their solution. I'm not everything to everyone, but who I can serve, I can go deep with. Who I'm serving are people who want to grow. I want people who are anywhere between 1 and 5 locations. I'll consider bigger companies but if you are between 1 and 5 locations and you have a desire to be free of your company, that's who I want to serve. My email is Will@TheProfitablePT.com and my billing company is called In The Black. We have a separate email for that, but I'm going to keep it simple for people. It's the same as my YouTube brand. You can call me. I don't know if I should give my cell out because I'm worried for the people that I will spend too much time on the phone with them. The email is fine.
Imagine this is after August 1, 2020. What's your website going to be?
My website is going to be InTheBlackBilling.com. We're super excited. We do have a vision of taking on another ten clients. We’re going deep with them and helping them blow their minds. It's such a fun industry to get into it because there's nothing sexy about it. We're bringing the sexy back in a way it's never been. I'm doing normal things you do in other businesses like appreciation and keep relationships strong. I love it. It's so much fun. I still feel like I'm treating is what it feels like. That's how you get ahold of me.
I don't know where this comes from in us because I've done the same thing with coaching clients. I've had people call me and be like, “I don't know if I'm the best fit for you,” or I said, “I don't want you to sign up with me unless you talk to two other people.” I've done that a few times and I'm trying not to say that because we're charitable human beings, but what I'm talking about and the way you presented is that's a true consultant and someone who recognizes the needs of the person that's calling and not necessarily your need to acquire another client. If people who are coming to get a consultation with you, maybe they're going to come away with a couple of nuggets. I do the same thing when people call me about coaching clients, whether they come with me or not, I try to give them a couple of words of wisdom and I share my experience. It’s the same thing for you. You're going to say, “You might want to look at changing your EMR or stay with your current EMR or stay with your current in-house billing person,” but add a couple of statistics or reports that would make them more efficient and hold them more accountable. That's what a true consultant would do.
What we offer is a free profitability breakthrough audit and I've done this a number of times where people will give me their data. We sign an NDA. I completely show them where there's money. There hasn't been a single time. I've done twenty of these at this point. I've never found less than $10,000 sitting in absolute profit in their business right now that we can’t go and get.
That's bottom line in their pockets if they simply made a call or two.
When I show them that, they don't move forward with us because they only needed some tweaking with their existing solution. What you said, I've heard it said differently and I love this, which is, "We can help everyone but we can serve only a select few.” Who we serve, instead of going a mile wide, we're going to go a mile deep. It's a little selfish for us to be helpful for everyone because that's the only way we can find those who we can go deep with. That's where you and I have learned from people like the coaches you've mentioned. They go so deep. You think of them as family, like a father. You can’t separate that. I'm so excited because I know that's what's happening on your end with your clients. I'm grateful that you're doing it. I see you being a master coach in this industry. You already are, but this is your first group. I’m putting it out there in terms of intention that Nathan Shields will have that name of a major influence in the coaching world of our industry.
As long as it gets me out the door and on the leg by 2:00 PM, that's fine. Thanks for your time. Much love. It's always great talking to you.
Thanks again for having me.
Will Humphreys, the Profitable PT, is the CLO and co-founder of In The Black Billing compnay and has been a PT for 20 years. He owned a multi-locational outpatient practice for 12 years before starting his new venture with Katie Archibald. He is a father of 4 boys, married for 20 years, and a part-time comedian. He is passionate about physical therapy, entrepreneurship, and the freedom that is created through profitability.
Love the show? Subscribe, rate, review, and share!
Getting patients to enter the door may seem simple but is actually one of the hardest steps PT clinics tackle. Today, Nathan Shields talks to Peter Decoteau, the marketing director at Physical Therapy & Sports Medicine Centers (PTSMC), the largest privately-owned PT group in Connecticut. Focusing on breaking down any barriers that keep new patients from coming in the door, Peter recognizes that the first barrier for a majority of people is simply knowledge - not enough people know what physical therapy is, thus your message has to recognize that. He shares aspects that make these technical such as location, insurance, and those can be further addressed after you've captured their attention. Peter believes that regardless of the steps taken, it is necessary to know what your brand is, who your ideal client is, where they get their information, and the content they need to hear all of which leads you to begin to generate marketing campaigns.
My guest is Peter Decoteau. He is a Director of Marketing for a large physical therapy company in Connecticut. I brought him on because I want to talk a little bit about a couple of things. First, the things that we need to consider as we are advertising directly to our local community or direct to consumer marketing. Secondly, what are some of the things we need to do on the back end, which is number one, how did we get that patient who is interested to convert? Number two, how do we track the KPIs related to our marketing strategies.
Important stuff as we're considering that a lot of our marketing strategies need to spend more time and effort either direct to consumers, via mail, email, or social media and rely less on physician referrals. That's the trend that we're seeing. I'm trying to highlight physical therapy clinics that have been successful at doing it. If you do have a marketing strategy, I’d love to see how yours compares to what Peter represents. Also, if you don't have a marketing strategy, consider some of the basics during this episode that you need to do to be intentional about your marketing efforts to grow.
I've got Peter Decoteau. He is the director of marketing, Physical Therapy & Sports Medicine Centers, Connecticut's largest private practice group. I wanted to bring him on because I saw a past impact magazine article in which he talked about marketing. I'm always open to that and we need to consider marketing outside of the traditional physician relationships. Based on his article and further talking with Peter, I wanted to talk a little bit more about marketing and some of the things that we need to do and look outside of the traditional relationships or things that we're doing. Peter can give us some light and insight into how to make it easier for new patients to get in our door in general. First of all, Peter, thanks for coming on. I appreciate it.
Nathan, thanks for having me. I'm happy to be here.
Give us a little bit of breakdown about you. You're not a physical therapist by trade, you're in marketing, but tell us how you got into this all and your experience with physical therapy.
I came into physical therapy cold. I didn't have any experience with physical therapy personally. I had not gone through physical therapy. It's an interesting experience to come in not knowing too much about the industry. I have a strictly marketing background. I started in a nonprofit in Hartford, Connecticut and then moved onto a private school up in Simsbury, Connecticut. I was an ad agency for a little bit as well. The benefit for me of having those experiences and coming into this environment is that I have a pretty broad breadth of knowledge in terms of different approaches to marketing. The different pieces of marketing like PR, digital or advertising, all those different things that you'd want someone to be doing.
A different perspective.
Working with different audiences. If anybody out there has worked with a nonprofit, they would know that you were pretty much every hat possible there. It was a good starting point for me. I was doing some multimedia marketing for them, but I was also doing some membership relations and some sponsorship relations and things like that. It gave me a good foundation for where I wanted to go next. The opportunity to come into Physical Therapy & Sports Medicine Centers came from working with someone in our leadership group. I was working with her husband at the private school and they needed someone to come in and do a little bit of consulting for some of the digital marketing and social media stuff that they were looking to expand upon and reach a broader audience with. I jumped on as a consultant in that way. I did a pretty extensive audit of their digital presence and gave them recommendations and I was doing some ongoing work with them.Do whatever you can to break down the barriers for new patients to get into your clinic. Click To Tweet
When the opportunity came out for a marketing director to jump on board here, they reached out to me and things were tumultuous at the ad agency. That's a different story. Suffice to say that they don't exist anymore. It was good timing, jumped on board here. I had already been working with the team here. I knew that it was a good fit and I was interested in coming into the physical therapy world knowing that it'd be doing something that at the end of the day is helping people. Not necessarily for me doing the hands-on treatment, but getting people into the physical therapy clinics, especially clinics that we have that I believe do top-notch work. It felt like it was a good industry to jump into.
That's cool that we have you on because you bring a different perspective than the typical physical therapist that might be talking about marketing. I want to ask you, are there some false ideas that physical therapists have about marketing and how it should be done that you have to come in, break down or challenge and change their perspective about it? If so, what might some of those things be?
The number one thing that I've seen, in coming into the industry and being a part of the private practice section committee, is that physical therapists greatly overestimate how much the general public knows about physical therapy. We tend to exist in an echo chamber of our making. In an impact article that I've put together, we're the fish living in this water all day. We tend to think that everybody else sees it the way that we see it. We talk to the general public. You realize that their knowledge about the scope of services provided through physical therapy, the way that you might come to physical therapy, even where their nearest clinic would be or the difference between outpatient and inpatient.
There's not a lot of knowledge in the general republic and that is a matter of messaging for the industry. For the most part, the industry itself was mainly surviving on doctor referrals to physical clinics. Most of the messaging had to happen from the therapists or if they had marketing people, which a lot of them didn't to the doctors and to trust there and build relationships there, which is still important. Given that direct access is something nationwide that came out in Connecticut. The focus should be on pushing forward on self-referrals, direct access, teaching people even what that means and what that is, especially the scope of service that we provide.
Tell us a little bit about that because that leads to our topic as far as how to get those new patients in the door, direct consumer marketing. It’s getting the knowledge out to the broader audience because the stack gets thrown around and I don't know where it was found. I wouldn't be surprised if it's true that only 10% of those patients with musculoskeletal injuries get the physical therapy that they would need or could need to overcome their injury. That means that all of us are fighting for a pretty small pie. If we're focused on the physician referral route, there's 90% of the population out there that could use our help that isn't getting it because they don't know about us. We take for granted that everybody knows about physical therapy or at least some version of it. Maybe they don't understand how physical therapy could help for minor traumas, for simple injuries and stuff like that. Talk to us a little bit about how you work to help those new patients get in the door from the population and utilize direct access.
I love that you use that number. That's a number that our Vice President of Business Development, Mike Durand. He’s been a part of this company and he was an athletic trainer before. He throws that out all the time and says the same type of thing. It's like, "If that's true, which the study shows that's the case, that we're all fighting for that little piece of the pie instead of working together to try to make the pie bigger for everyone." If we're talking about ways that we can increase self-referrals or increase our patient volume with people who are not coming directly from the doctors, is that we first focus industry-wide on our messaging and create a little bit of consistency.
At least acknowledgment to get the messaging out there in a broader sense before we start doing more clinics specific or company-specific messaging, if we do that successfully in terms of having clear, consistent messaging, talking about the benefits of physical therapy as a whole because that percentage of the pie gets broader. Even if there are fewer people specifically knowing about our clinic at some point, all the whole thing grows. We'll be reaching maybe more of a niche audience, but that niche audience is also bigger. Our patient volume still grows.
It sounds like your marketing starts with developing the knowledge-based of the community as to what physical therapy itself is and how you can benefit those people who are having less traumatic issues. Maybe simply low back pain, you're marketing your message is a little bit more knowledge-based and then you add your tag or logo at the bottom? How do you guys go about doing that?
We talked a little bit about this, something that David Straight had mentioned on a previous episode of yours, which I encourage everyone to go back and read it if they haven't. He talks about starting with establishing your brand identity and figuring out who your target audience is. Also, figuring out where that audience is in terms of platforms you can reach them most effectively. We always start there. Once we've gotten to that point, we know who we're talking to, we know who we are and how we're positioning ourselves and we know which platforms we're using. We get to this piece about the intellectual property that we can bring to that, the content that we can put together.
The value to the users or the audience while also educating them on this broad range of topics that we're talking about. That doesn't necessarily have to be broad with each piece of content, but that we're covering a lot of bases in the messaging that we're putting together. The more that the audience sees these messages, the more comprehensive of the picture they get and the more personality they get about our companies specifically. The pieces that I'd say differentiate us from the other clinics that are in Connecticut.
I love that you bring up David Straight's episode one of the few first episodes and you talked about marketing. The evolution of your marketing doesn't necessarily change. You've got to figure out who you are and who your ideal client is? Some people might say, "What is that avatar?" Once you have that figured out and what you do best and what patients you want to work with, then you can focus on, where did those people get their information from? Is it social media? Is it mail? Is it email? Is it postcards? Is it community events? You can focus on the content. Based on knowing who your demographic is, you can structure your content accordingly. To invite those specific people in the door, that's how you would structure your marketing program as you're going direct to the consumer.
In terms of what we're talking about with getting people into the clinic, educating the public both on an industry level and then on company or clinic specific level. What we're talking about is breaking down the barriers of entry to the general public. This piece of it that we're talking about is the barrier of knowledge. It's a general knowledge barrier that people have for physical therapy. What are the things that we can do that breakdown that knowledge barrier in a general sense of the benefits of physical therapy? That specific level of physical therapy can help with your recurrent back pain that you might not need surgery for but keeps you up at night. Here are the ways that our clinics specifically can help with that because we offer dry needling. We do hands-on therapy. We focus on the manual. We are closer to you than the other clinic. There are these other things that make us a better option for you. We can start from that broad sense and get more specific as we continue to try to reach that audience in the way, read the messages that resonate with them.
If you look at their websites and some of their content, they might focus more on the treatment they provide instead of the benefits they can provide to the patient. As we're talking to ourselves, we know the benefits of say, dry needling or some manual therapy technique but that's not what you want to highlight and advertise. You want to get down to their knowledge level and also, what's important to them, which are their functional capabilities and how you can improve those and focus there. What you provide is off to the side. This is how we do it. If you can simply get them to buy into what you're doing to improve their lives, you can talk about how we do it later on.
Our motto is improving the quality of people's lives. That's the thing that we always go back to because we do say that PT in general if you're going to a good physical therapist, that's what they're doing. They're improving the quality of your life because you can sleep throughout the night. You can pick up your grandkids. You can play rec league soccer on the weekend, which I do. I've needed to go back to physical therapy for that specifically to get me back out on the field. Those are things that provide quality to my life or somebody else's life that we're trying to get you back to. Starting at that point and then getting more specific.
I like to think about it and you talk about a marketing funnel, getting people down in the funnel and then wondering where do they go once they convert? I made up in a previous position. I tried to visualize what it looks like to me after they've converted and put a little bit of a tornado in the middle of the following, say, "If you've created the awareness and then you're getting to the point where the people exist in the middle point." Especially with physical therapy, which you want them to be aware of the fact that you exist and you have these benefits. Maybe that person doesn't need physical therapy but you want to be there for them when they do need it.
You want them to exist in this little middle part of the funnel that's like a little tornado of information that they can keep on receiving. How can we keep them engaged? How can we keep them interested? How can we get new little tidbits of information to them? That's the way that I like to think about it. The content marketing that we're doing that we are getting people to that point and then staying in front of them with all this relevant information that speaks to both the services that we provide, but also the personality and the differentiator points that we offer. When you talk about something like dry needling, you're right, we're not going out there necessarily promoting dry needling to the general public as a selling point for us.Reach the audience by reading the messages that resonate with them. Click To Tweet
Once you're engaged with us, we'll do videos about dry needling and talk about the benefits of that and show you what it looks like. I had the barrier to entry for that would be thinking that it hurts. Can we show you in a video that we're dry needling, someone and they're not reacting to it at all? We did a video with one of our clinicians. She specializes in temporomandibular dysfunction. She dry needled two parts of one of her aide's phases. We'll first show the type of treatment that you would be offering, but also, ancillary it showed that it did not hurt her at all. The more we can bring that type of content into the fold, the better.
As you consider breaking down the knowledge barriers and providing them what they need to know about physical therapy and how it can help them? Do you have a secret sauce when it comes to getting that conversion? If they call and they want to utilize direct access and come to you without going to a physician, what can you share about how you get those people to convert and become new patients?
I wish we had all those answers because that would be fantastic. That's something that we're working on daily. I talked to our operations people and our employees as much as I can about the things that we should be doing that are consistent. I see that as two separate things. One is the functionality of getting them to convert. The other is the interface with our employees when they're interacting with them on the phone or when they come into the clinic. The functionality piece is, we try to optimize everything we have. Everything that a potential patient might be interacting in a way that again, breaks down the barriers to getting them into the clinic.
For example, if you're someone who doesn't have any relationship with PTSMC in the past, and you probably maybe even not had a relationship with physical therapy in the past or you've had a bad relationship with them, which is something that we hear sometimes. What's the information that you're looking for? How are you looking for it? How can we get it to you faster and easier and more effectively? How can we make it easy for you to book an appointment? Ideally, what's happening in the person's thinking, "I need physical therapy." The doctor said, "You need physical therapy." I'm going to tell you to find your therapist, which happens more often. They go to Google, they search for it. You come up, they go to your website, they're looking for maybe, do they take my insurance and do they offer the treatment that we're looking for?
We know that those are two things that people are looking for most often than not. Are you getting them to the right page initially? Is it easy for them to find that information? Once you've given them that information, how easy is it for them to book an appointment? The way that we have it set up for us, our organization is that we built a new website specifically with that user process in mind. It's optimized for the user flow. Also, for the SEO flow to the individual pages, search engine optimization flow. On purpose-built out landing pages for every treatment option. We've got that landing pages for every individual clinic so that if you're Googling, "Best physical therapy in Avon, Connecticut." If you do it in Connecticut, the first three things that probably show up are one, a Google Ad campaign that's running for that says best physical therapy in Avon, Connecticut, that when you click on it, it goes directly to Avon's location page.
The second thing that shows up is probably the organic result for that. The third thing that shows up is probably either the maps result or staff result for the same thing. We're trying to dominate the search results there as relevant as possible. When they get to the site, make it easy for them to find that additional information. We have, I believe, two or three conversion points for submitting a request for an appointment through the website on every single page. There are a floating button, a sidebar and a top bar that says, "Request an appointment." Everywhere on the site, it's there, it's ready to go.
Whenever you want to request an appointment, we're ready for you.
Ideally, what would happen is that they would click on that and they'd be able to integrate with your scheduling and requested an exact date and time. We're not there yet. It's somewhere that I would hope for us to be pretty soon. Also, there's some friction in terms of what's available in someone's schedule. Maybe it's available for a reason that you know all about because I'm not in the clinic. It was a little bit of like, "How much can you do there?" You're breaking down those different barriers to book an appointment or they put them to call and they're going right to the clinic that they're trying to.
It's great that not every individual practice owner is going to have a director of marketing like you to handle a lot of the Google Ads, the SEO and stuff like that. What it shows is, we put out some marketing promotional material or an ad, you name it, but in what you've done intentionally is, how can we make this as easy as possible for patients to get in the door and make an appointment and convert? That's a necessary exercise for any owner. That is to say, we put out this ad when someone calls or when we're calling out for a referral, how easy are we making it? Are we forcing them to give us all their insurance information before we answer their question? Are we making them jump through hoops and getting the date of births and that stuff?
Are we more focused on them and maybe what their name is? What their ailment is and how it's limiting their life, maybe establishing that relationship right off the bat. I'm saying there are other ways that you can go about it and it's worth the exercise for owners to sit down and say, "At this touchpoint with a potential patient, how can we break down the barriers?" Maybe they've got an understanding, a knowledge-based. What can we do to make it as easy as possible for them to make an appointment? Everything we can or in that call and I'm sure you're doing it with your calls. You're also doing it with your website. How can we make it as easy as possible for that internet traffic to translate into a visit as well? You can look at those touchpoints and say, "How can we make this as easy as possible?”
You bring that up and that speaks to that other point that I was talking about the interface part of it. One of the things that we try to do, everything I was talking about the functionality wise is called technical side of it. At the end of the day, we always have to remember that we're dealing with people who are probably in some pain or representing someone who's in pain. Not only that, but they have to deal with the pain of going through the healthcare process, which is usually not simple. From that point, can we come to them from a perspective of empathy? Can we make that part of it easier? When they come into the clinic to treat the real pain that they're dealing with, they haven't had to jump through all these hoops beforehand?
Typically, what we do on that end is a lot of different folds to it. I would say that our operations group does a good job of onboarding people to the particular culture that we have at PTSMC. We focus a lot on the differentiator for us being one of the tenants of our mission statement is lifelong relationships. That's a key tenant of that. We want to be known as the physical therapy company that focuses on, we say that the person, not the problem. When we onboard people, we focus on that as a key element of everything that you do when you're working. You're getting people in a database and your scheduling. You're first and foremost, a representative of that philosophy that we have here.
Likewise, we do that with our clinicians too and we have to do that with the front desk people were feeling most of the phone calls. Another thing that we do that speaks more to the marketing side of it is we do a separate onboarding event process with all new clinicians’ call, "Living The Dream," which is they met our president loves to say. We've got to wrap it into that. It's focused more on that what we call the soft skills that you don't necessarily learn in PT school that are related more to that interpersonal piece. What's beneficial for me as a marketing person to be involved in that is again, not knowing that I'm not a physical therapist and I'm not having these face-to-face interactions with them. Giving them some more consistent tools to bring to those interactions that might help the growth of both their client base and the clinic more broadly has been useful for them. Sometimes it's something as simple as always have business cards on you.
When you're discharging a patient, if you think that they had a positive experience, which we think that most people do and our survey scores reflect that, give them a few. You can say, "I'm your person. I'm your PT. Hand this off to any friends or family that you think is dealing with pain and tell them about direct access because people don't know about that. Let them know that you've got a guy and I can get you in as soon as possible." That little intimate touch of saying like, "You've got a guy, here some cards, and bring other people into the fold." It both allows you to get that word of mouth out there for the referrals, but also, it puts the value into their hands that they've got a connection that they get to reveal to people who are in their circle enough to take advantage of. We do small things like that.
As you're Looking at some of these efforts that you're putting out, are there certain KPIs that you follow to see if these are being effective or not? You brought up Google Ads or SEO costs, how do you measure KPIs or ROI on some of these things?
I tell partners at all the different clinics and this is my number one byline to all of them. My job is to get people into your doors. That's the ultimate thing that I do. If all else fails, if we're getting more people into your doors from a marketing perspective, then I'm doing my job. Their job is to provide world-class physical therapy care, so that people want to spread the word and come back as return patients. Let their friends and family and colleagues know and all that stuff. We do a lot more than that in terms of supporting brand awareness within the clinic and supporting the clinicians to get out in the community. The number one KPI for me to answer that question is that if we're getting more patients into the door, either self-referred, returning patients or referred patients, then that's the number one KPI. In terms of tracking the performance of individual campaigns that we're running, it's a lot easier to create KPIs and track them when it's coming from a digital campaign. For Google ads, you can track the clicks through to the website and the conversion rate from those clicks.PT clinics must remember that they are dealing with people who are in pain or sending someone in pain. Click To Tweet
There's direct percentage of saying, we have a little bit of an equation that we use that's like, "If we're spending $300 a month with this clinic on Google Ads and we're seeing six conversions through that ad campaign because their phone calls and requests through the website, we're going to estimate that only three of them are coming in. What are three patients worth in the life cycle of a patient coming for ten treatments?" The average is nine or ten. That return on investment might be $3,000. We can say those numbers of conversions and the percentage of click-throughs and say, "For that ad campaign, we're getting a ten-time return on investment of those numbers." You start to look at that and say, "How can we get those percentages higher? How can we tweak the campaigns?" Those are the types of KPIs that we start to focus on in terms of like, "We want to get more conversions through that, how can we do that without blowing out our whole budget?"
What's a percentage of return that you're expecting typically? What is the sweet spot for you at least this number and above?
We tend to see it. It works out well because we have the 25 clinics, soon to be 26, where I built out from the start a few ad campaigns on Google and optimize them as much as I could, knowing what our budget was going to be. I pretty much copied them and duplicated them down, changing the location information in the contact information. We're working off of these few optimized ones. We're the good month for one of them, we might see a 10% conversion rate, which is pretty good. Typically, we're probably seeing 4%, 5%, or 6%, which is still pretty high I as an industry average, which is good.
You work with a large company and you had soon to be 26 locations, what would your recommendation be for a guy that's only got one or two locations? He can't bring on a full-time person for marketing, maybe has room for part-time to find somebody or maybe as needed for a campaign. How would you recommend they go about looking for marketing help or doing it themselves?
I always say to start with the low hanging fruit. In this case, if you had to pick out two people who are your ideal client personas whether those are based on payer mix. Maybe you have enough volume, but you want to get volume from a higher payer or payout. Maybe it's volume focused specifically. What's the low hanging fruit in terms of the people that you know or in your area that need PT who aren't getting it or don't know about you? Start with the groups that you would most like to reach as the low hanging fruit, easiest people to get to. Figure out where they are and be specific about what you're doing in terms of the platforms that you're using. One of the things that I tend to see, and I saw this at the ad agency too, that we would bring on clients who wanted to do everything.
They were only working with the small budget or maybe it was a small organization we were working with. We dealt with a lot of that and nonprofit because nonprofits don't have a lot of money for marketing. You want to do a little bit of everything. You want to chase every new trend and you want to be on the TV and get the print ads and also do the social media thing and do the Google thing. It's important to focus on those audiences and focus on where are those audiences are or those audiences are and be that targeted and specific. It's better to maximize the effectiveness of something efficient in terms of your budget and your resources and time that you can put into. Rather than spread yourself thin and maybe see success at a few of those different things which are using up way too many resources. Be specific.
You've brought up a couple of things. Number one, be specific. Focus your marketing efforts on something and focus on that only instead of trying to hit every button out there. You also brought up something else that it's important to bring up in that is most small clinic owners don't necessarily have a budget. Number one might be figuring out what your budget is for marketing or this campaign, and then set that money aside and limit yourself to that budget and see what it does for you. Make sure you're measuring it appropriately. I brought it up with David Straight and I also brought up with Neil Trickett. What your budget is for marketing can vary wildly simply because if you're a startup and you're new. You're opening up a new location, while you want to put more money aside for your marketing purposes and may be up to 10% of your gross revenues if necessary.
Whereas if you're going along and you're nice and steady, you've got a reputation, you've been around a long time, maybe that number pairs down to 3% to 6% of your gross revenues for marketing. Number one, come up with a budget first. I like what you said, "Focus on what you want to do." How do you focus while you focus on where your demographics are? Who do you want to hit establishing your brand identity? Who's your typical patient, the ideal patient? Focus on those platforms with that predetermined budget. That budget can allow for maybe bringing someone on as needed to fulfill that campaign for you or doing it yourself if you have the capability of doing so.
I'm in a unique position at PTSMC because the way that the partnerships operate is at each clinic technically has its individual budget. We all have things wrapping up into a broad marketing bucket budget for us to work with for the most part. I have to have these conversations with each partner at the beginning of the year and then in the middle of the year when things are rolling out. The piece about, how much are you willing to spend to maybe test a couple of things out to see what works? How much are you willing to spend on things that we already know works? What's that breakdown look like? An important piece of it, what are you doing to drive organic results as well? Things that don't require too much of a budget and that's when we get back to this knowing the language to talk about self-referrals.
Having the knowledge and the language to use in talking to patients to tell them to talk about you're going on in the community or leave reviews on Google, leave reviews on Facebook, things that you know have a pretty high yield do anything asking for those things. I was talking about this piece of patient interaction that's called the point of delight. It's a marketing term that speaks to this point where people, I've received great service and they're looking for a way to reciprocate. Especially when it comes to physical therapy. They may not be paying too much for it. Hopefully, their insurance company's paying for it.
Maybe there was small copay, but they don't feel like in terms of the monetary interaction that's happened, that they've necessarily reciprocated for the service that they've received, especially if you're building a relationship. That is trustworthy, caring, they feel like they need to do something to make it up to you. Catching them at that point and saying, "Would you mind leaving a Google review or going on Facebook and sharing some of our staff or I would think most value telling people about us." That's free advertising for you. Having the language to do that, it doesn't require any budget, once you get that point if you're doing those things and you want to continue to grow and expand your patient volume, yes. How much are you willing to spend? Are you willing to test out a few different things?
Not spreading yourself thin, but you did the research, you looked at your analytics, you know that they needed the demographics, they're trying to reach out to you. This is where they are. Let's try a couple of different AB tests and see if we can track results there. Also, having the tracking measures in place to know if it's working or not because I've seen a lot of that too. Where it's like, "We're doing the social media stuff or the Google stuff." It's like, "How are you tracking performance on that? What does success mean to you there?" "We want to see more patients." Like, "Are you separating them and tracking them individually to see that this one's working, this one's not?" It's having all of those points in place before you start rolling things out.
It's important to ask the question, "Do you want to try new things or do you want to continue with what you're working on that will determine your budget?" You're going to spend a little bit more, but you don't want to forsake the stuff that's you've got going already. You want to continue doing what you're doing and then if you're going to do something new, make that an add on so you can see the benefit of it. You have to be intentional about that and plan those things out.
Don't be afraid to cut off the things that aren't working. We saw a lot of that when I came on board originally. We have relationships that had been going at certain clinics, whether or not they're community relationships where we pay $1,000 to be a part of this event. Also, print relationships where we have a monthly percentage of the budget going to these print ads for these smaller local publications. I'll see value in those things, but typically it's not that top-level value. I see a lot of value coming from people reading the paper and seeing the admin like, "I should go to physical therapy." For me, is there a way to leverage that relationship? Can we talk to the sales rep or the smaller publication?
Usually, it's a small staff to leverage the consistency of advertising into actual news coverage? Those things have a value that you might be able to parlay your investment into it, unlike a regular basis. For the most part, you come in and you see that we're throwing a few thousand dollars a year at this print ad stuff and we haven't done any of those relationship pieces. They're expecting it to keep on coming in and you pull the plug and talk to the clinician and say, "Do you know if you're getting any new patients out of this?" I would say, "Someone mentioned it to me one time. I don't know." We'll try to create some metric for measuring success there, but if we don't see that in the next twoReviews are reciprocations of the services clients receive. Click To Tweet
Move that money somewhere else that's more effective. Anything else you want to share with us before we take off, Peter?
I'll say one thing and this is a call out to all physical therapists out there, whether or not they have a marketing team or if they're small staff doing the marketing for themselves. I'll push this again because we talk about it a lot at the PPS and APTA and all this stuff. For us, a rising tide certainly lifts all boats. We as an industry, do have a great opportunity to take advantage of the huge percentage of people out there who need physical therapy but aren't receiving it. Also, for some reason aren’t getting the information about the benefits of physical therapy, the scope of services that we have. The ways that they might be able to bypass whatever healthcare system they were working within using referral direct access to come straight to your therapist in ways that that might save you time and money.
If we can be more consistent in not being necessarily self-serving on a marketing side to talk about, we're the best all the time. Let's talk about physical therapies the best because it's a part of a healthy lifestyle. If you commit to it and if you build a relationship with the physical therapist in a way that you might have a relationship with primary care doctor, attendant or anything like that then. Down the line, first off, that's a longstanding relationship that you have. Also, that person's going to have a healthier lifestyle and be able to maintain activity and stay active in the older age. For me it's more about broad messaging, getting those talking points out there, direct access, the scope of service, and then being specific about what the differentiators are for you. That speaks to your brand identity as you've outlined it.
I love the insight and that you're willing to share some of what you guys are doing. I appreciate that. If people wanted to reach out to you and ask you questions or where you might be doing, are you willing to share some of your contact information?
Sure. I'll share my email, Peter.Decoteau@PTSMC.com. Always feel free to reach out to us on Facebook. You can message us on Facebook. We have one account for the whole company. We try to keep it all tight together.
If people want to check out your websites, you were talking about the Google Ads that you use and how you set things up to allow people to request a referral or request an appointment, what is the company's website?
It's easy PTSMC.com. The individual locations are available there. Hopefully, you'll see in the coming month we're rolling out. This speaks to the idea of breaking down barriers, but we're rolling out an AI chatbot on the site. The goal of that is to get people to the information they're looking for as quickly as possible. We know that people are looking for insurance location or treatment. It pops up and says, "What can we help you with?" If they don't need any things, it goes like, "Here it is." Try to get people to the stuff that they're looking for.
We'll have to check it out. Hopefully, it's already in place.
Hopefully, it's in place and it's all working correctly. If it's not, you can email me and tell me that it's not.
Thanks for your time, Peter. I appreciate it.
Thanks for having me on, Nathan.
Ben has been a member of Teton Therapy since May of 2010. He graduated with a Doctorate of Physical Therapy from the University of Mary in Bismarck, ND and conducted his field work primarily in out-patient settings while in school. During his time at Teton Therapy, Ben has taken many continuing education courses on topics such as Dry Needling, Kinesiotaping, neuromuscular re-education, running analysis, and injury prevention—a topic which he immediately found a passion for and has since conducted classes to the community. Ben quickly applied this vast amount of knowledge to the practice and sharpened his therapy craft. His general interests include water sports, running, outdoor activities such as camping, competing in triathlons, and most importantly spending quality time with his wife and children.
Love the show? Subscribe, rate, review, and share!
This is Steve Rapposelli. I'm a fellow PT owner and I have hijacked Nathan's show because we have turned the tables on Nathan. Nathan needs to have the tables turned on him, so he does not know what I'm about to ask him, but here's a little bit of background. Nathan was nice enough to interview me for his show. You may or may not have read it. That's not important, but as I was talking with Nathan and as he was interviewing me in a very inquisitive, friendly way, I found out that he would not be the guy to say that to you directly. I'm taking it on myself to be the interviewer and to ask Nathan a little bit about his story because quite frankly, it's fascinating. It is a story that you are going to want to hear as a fellow PT owner. This is why I think it's important.
If you're a PT owner like myself, whether you have one clinic or five clinics or 100 clinics, you probably have the same questions in your mind that he did and that I do and that is where are we going here with all of it? What is the next step for me as an owner? Nathan has already walked that path and the story that we're about to reveal is going to be one that you're going to find entertaining, learn a lot from and help you on your journey. You may likely take a different journey than Nathan's and that's okay. Nathan has his own path, but it will help guide us as a way of comparing and contrasting where you may need to be. Without further ado, I'd like to introduce Mr. Nathan Shields. Nathan, are you there?
Thanks for having me, Steve. I appreciate you having me come on my own show.
We are glad to have you on your own show and I want to get right down into the end of the nitty-gritty. I know that your story is searchable in the wonderful digital land of Google, but we need to have it lying in your own show archives because it's very interesting and it's very instructive to your audience. With that said, you're a guy who got his training Northern Arizona and upon graduating back in the late ‘90s, you opened up a practice in the Phoenix area. Tell me about the path that you took when you first opened your office in Phoenix.
I opened up my clinic in 2002 and that was in Chandler, Arizona. My whole goal was to get to two physical therapists, 150 visits a week and afford a TiVo. I thought if I could get two PTs, 150 visits a week and get a TiVo, then I know I've made it and that would be all. Lo and behold, I worked hard for a number of years and I opened up a satellite office in Florence. I got a friend to manage that for me. That ended up being my business partner, Will Humphreys. He managed that. He eventually bought that clinic from me. Together, we opened up another clinic in Maricopa, Arizona. We ran like that for a number of years. Each having our own success, we had his and our situation, but we shared common consultants. We knew that we needed help. We shared a similar networking group, a small business networking group. We found out, like most of us do that, “I don't know what I'm doing business-wise. I can treat patients all day long and they're happy, they get results, but I hate doing the business stuff.”
You said, “We needed help.” How did you know that you needed help?
If you read my interview with Will, he knew he needed help because he had a breakdown. He had a stack of charts that he was going home with every night. He was driving in the middle of the summer in Arizona at 115 degrees in a little truck that didn't have AC. He was sweating through his clothes. For me, I was the guy that was staying up all night doing charts. I had employees that were upset with me and upset with the company, who didn't know who to talk to. I was upset with them and frustrated that they weren't simply doing what they were supposed to do, even though I didn't tell them what they were supposed to do. There were a lot of frustrations and I knew there's got to be something better. I also knew that if I continued down this path of working 60 hours a week and then trying to run the business on top of that, there was going to be a burnout. I couldn't keep doing that. It was at that point that we figured we needed some help.
What help does a PT owner seek out when they reach that a-ha moment?
They can do a number of different things. You can start reading books. You can start googling and looking up webinars and YouTube channels of other PTs that have been successful. You can reach out to a podcast. Nowadays, there are many more resources available to us at our fingertips as PT owners than there was back then I believe. Even the APTA has provided some good materials through PPS to help someone get started in a clinic, but there are many more consultants. There are many more companies. The internet is much more available so you don't have to feel as alone as I did back then in the early 2000s, starting at the clinic. There are many more resources now.
My mantra is to reach out, step out and network. That's the common formula for success that I've found in not only in my experience, but also the people that I'm interviewing. You got to stop treating full-time. If you're going to be a business owner, you've got to put it on your business owner hat a couple of days a week and act as the leader of your company and that you own a business. Forget that you're a physical therapist almost anymore because more than a physical therapist or an owner, you've got to get some support, some outside perspective. You've got to network.Reach out, step out and network is a common formula for success. Click To Tweet
Did you seek out a PT-specific coach consultant?
We had a personal/business coach, someone who helped us at different times as a parenting coach. When I say us, that's Will and myself. We found this person who was providing parenting seminars because we were new parents as well. That'll add to the stress. She also did some business consulting because a lot of it's about relationships, whether it's parenting or interpersonal relationships with the husband and wife or relationships that you have with your employees. It's about relationships. She did some coaching with us, but then we also reached out to a PT-specific consulting group, Measurable Solutions at the time and got some help in that regard as well to help us organize and establish structure and systems in our company.
Are cutting-edge PT owners ever done seeking coaching/consulting?
If you're me personally, I don't believe so. Consider the professional athlete, they're at the top of their game yet they still have coaches. I listened to a podcast about The Trillion Dollar Coach or something like that, but Steve Jobs had a coach through most of his existence as the CEO of Apple. It’s the same thing with the guys at Google. They have coaches. They need another perspective. They need some insight. They need someone to hold them accountable if they're going off the rails and not heading towards their goals. I believe that everyone needs a coach.
In your opinion, one consistent behavior of success of the PT owners that you've interviewed and interacted with is ongoing and regular coaching to help them grow personally and professionally.
I believe so, yeah.
That's good to know. Here you are back in the early 2000s. You're running and gunning with Will, everything is going well. For those of us who are not in Arizona, I assume that those cities that you identified are in that whole Phoenix Megalopolis area. Tell me more of your mindset at that time. Were you like, “I got the two PTs, 150 visits a week and the TiVo. Now we have two other offices. Let's just rinse, wash and repeat.” Where did you evolve from there and why?
The ultimate decision is to get some consulting help. I don't know how to put my finger on it. We have another physical therapist on here with us, Sean Miller, who might've gotten through the same experience. My thinking at that time is, “We can't keep doing this.” When I think about what this is, it’s that I'm treating full time. I'm running my business. I don't have a lot of time with my kids. Maybe financially I'm doing all right, but I'm not able to enjoy it per se. I didn't feel like I had a lot of freedom. I felt like I was a slave to the company. The company didn't work for me, which is the ideal situation. I knew I needed help at that time. You and I both know, everyone knows who's reading this blog, we haven't had any business training, so I also didn't know what I didn't know. I knew I needed some outside help to do that. Did I answer your question?
That statement you made of, “I can't keep doing this,” resonates with a lot of your audience. That’s a very scary place to be because you're leaving a comfort zone of you treating people and making the donuts so to speak. To leave that to then work on your business is not an easy transition for most clinicians/owners.
I believe a lot of us are high-achieving people. If we've gotten through physical therapy school, that's a common trait for all of us and we are very comfortable in being good physical therapists. Looking at it, if you were to say, “You're not going to do any physical therapy and you own a clinic, what are you going to do?” Most physical therapists might not know what to do to lead their company. They might go over and pay some bills or they might go market some doctors, but what are they going to do to achieve their company goals? That might be hard for us to accept, to set aside the physical therapy hat and put on a business owner's hat, one that we haven't been trained in. It can be an uncomfortable transition.
Once you had reached that point, Nathan, were you ready, willing and able to make that transition? Did you still have to be dragged into it by an outside person?
There was definitely some trepidation because if you get down to some numbers, you're thinking, “If I'm not treating on the floor and I hire someone else to take my place, I'm losing money at that point. There's a decrease in profit margin because I'm taking on the extra salary.” I’m no longer “productive.” I can't equate my time, which is time with a patient, to an outcome of money. It's hard to go from that to, “Now I need to set up a marketing plan.” You can't make the immediate correlation between my time and the results of that marketing plan.
You went from considering yourself productive to being one giant expense for your business.
Yeah, that's where it took a lot of mindset training. Maybe speak to this a little bit too, Sean, since you're on here. If any of you remember Sean Miller, he's one of my first episodes on the show and he went through some training as well. Maybe you can share your experience, Sean, in the same way, but I had to go through that mindset training that, “I'm not a physical therapist anymore. I'm a business owner who happens to provide physical therapy sometimes.” It’s to make that transition, to recognize that if I'm going to grow and make the company do what I want to do, I've got to work on the company to make it do what I want to do. Simply providing more patient care isn't going to get me there. You have to work yourself through that over and over again to wash that all out.
I couldn't agree with you more, Nathan. I appreciate you guys having me on with you. That was a huge mindset shift for me as well. You're a full-time clinician treating patients. I remember working with a consultant and the first thing he told me was, “You need to block off five hours a week to work on your business.” I was like, “I can't do that. There's no way I can do that.” When I did it though, I said, “I'm going to trust this process. I hired this guy to help me for a reason and I'm going to do what he says. Even if I ended up losing money, we're going to do it to see what happens.” As we all know, when you set aside that time and you start working on your business, you are automatically starting to see results and all of a sudden you realize, “That was a good idea.” It is a mind shift change because we're not used to that aspect of thinking we should block off time instead of being with our patients
Sean, you bring up a very good point. I want to hammer it again. You said something that was key and that is you brought in a consultant who told you what to do. There are so many people out there who then will disregard that advice that they paid good money for. You happened to take the advice that you paid somebody to tell you. How difficult was that?
I was telling a lot of people in our company this story and it was that when I first started with this consultant and they were recommending all these things that I needed to do in my business to improve it, I was super skeptical. I was like, “No way. This will not work. This is not going to help my business. I had to stop and check myself and be like, “What I've been doing is not working or has given me lots of more work and headaches and stuff.” I told myself, “I'm going to go all in. If I totally disagree with what they're saying, I'm just going to do it.” Part of me was like, “I'm going to do it to prove him wrong, to prove that what they have here doesn't work.” I've put it in and started doing everything and all of a sudden, my business started growing way more than I ever had done before with this. I've proven myself wrong with it. It's that mind shift change. I love the saying, “When the student's ready, the teacher will appear.” There's so much out there that when we're ready, the teachers will be there for us.
If you're not ready to learn the lesson, it will keep showing itself up on your front door. Nathan, I know that there's a lot of ground in between these two points, but at one point you said to yourself, for whatever reason, “I’m going to end this and I'm going to go to Alaska.” I know there's a lot in between there. Here's a guy who is successful in Arizona. He's got Will working with him. He's got a number of clinics and now you have this idea of an exit strategy.
Going to Alaska wasn't necessarily the exit strategy. There was a goal there that Will and I had that I was going to develop this diagnostics business. We did so in Arizona, we started some in Alaska and it started getting better. We had been doing diagnostics for a couple of years and it wasn't getting any traction. We recognized that we weren't putting that diagnostics business into its own structure. We considered it this small department within our current structure. No one really had any ownership of it and so it didn't go anywhere. We had some ideas around it but we never really focused on it. We decided, “If this is going to do something, one of us needs to take responsibility for it, make it its own business and set up its own entity.” I took over that. The agreement was that Will was going to focus on developing our leadership team so that he could free himself as well up from the day to day of the Rise Rehab at the time.If the owner actually owns the company and is not one of the laborers within it, then there's some value to that. Click To Tweet
How many offices did you have at that point?
At that time, we had merged. We had that his, his and ours and we eventually merged. We had four clinics going.
I believe it was close to twenty when you partnered with Empower PT?
We didn't necessarily grow our clinics from four to twenty-plus. We simply gathered a bunch of people together to put ourselves on the market.
That's the interesting part. Here you are as your own entity, Rise Rehab. You're in the Phoenix Valley, I guess you call it, the area and you say, “I can sell my four clinics to a national company or I can partner with these other independent practice owners and roll it all up and market that out and sell it as a bigger package.” Is that correct?
Not totally. You make it sound like I was the brains of the operation. I definitely was not. This is why I'm glad we have Sean on, because he was in Arizona when a lot of this was happening. Will and I, we had a number of offers for our clinic over the years. People had approached us maybe three or four times and each time it was some variation of, “We'll give you 70% of what we consider the value of your company in cash. You guys maintain 30% and you become essentially clinic directors or middle management. Keep doing what you're doing.” That didn't sound exciting. We didn't get into it to become employees again per se. We'd said no a number of times. Like I said, this happened over the course of maybe five or six years.
This is a conversation that a lot of PT owners have and it can be very disheartening after you've spent all your blood and sweat and tears building this baby of yours and somebody comes in and says, “We're going to give you X amount,” when you thought it was going to be 3X. That might've been your feeling as well. What then gave somebody the idea to look around the area and say, “If we do this a little differently, it can be more than what the parts are?”
For sure. We got some of those offers. We were a little bit disheartened. There were some that were better than others, but we're still relatively young. We'll focus on growing more. We're developing a leadership team to take off the day to day and we'll make it their job to grow the next clinic and open it up and that kind of stuff. A few years ago, a friend of ours, Jared in the Valley, he's someone that we talked to about selling our companies in the past. He came to us and said, “I work for a company that has some physical therapy clinics.” He was essentially the business manager, but he's a PT and they wanted to divest their physical therapy stuff.
He said, “I have an offer on the table.” I know I can get more if we essentially increase our value by increasing EBITDA, profit margins and revenues and that stuff. We can attract a bigger buyer who will pay more in multiples and that stuff. He called my partner Will and he was like, “That's a cool idea. Let me think about it. I'll talk to Nathan.” From what I recall, Will sat on it for a little bit and then Jared called him back a month later and said, “What'd you think about it?” He reached out to me. I said, “I think it's a great idea if we can do what he says he's doing. We could get more for our four clinics than we could on our own as the four clinics.”
We started making calls and that's where we reached out to Sean. I reached out to a couple of other people in the valley. Jared did some of his own footwork and reached out to some people. We started collecting some guys who were, and correct me if I'm wrong, Sean, in the mindset of, “If we can take advantage of the current market, it was a hot PT market a couple of years ago, we can get a higher multiple than what we can get on our own. It’s a buyer that we think is cool. We would consider it.” We didn't have any ties to it at the time. We had this loosely-held NDA between us. We formulated things together and got all got on the same page.
Let's use Jared as an example. Your business did not have to have shared resources or procedures or processes as Jared per se. Is that true?
Per se. Sean, how would you describe that?
Essentially, we ended up with five different entities with different policies and procedures, but most physical therapy practices were very similarly aligned. We had some that were stronger than others in terms of being organized and structured. It wasn't a unique situation. I've never heard of it happening anywhere else before, but it wasn’t a unique situation for sure.
Sean, to use a vernacular here, was it like herding cats?
In the beginning, it was a lot of work. It was like herding cats, but to the point of why we did it as well helps in this discussion, for me anyway. It’s to paint the picture that the market was hot, the timing was good and it was the right concept that if we do come together as a bigger entity, there is more value there, which then increases the sale price of things. 26 clinics are worth more than my four clinics, essentially. For me, something that everyone has to think about when they go to sell their practices or whatever they want is I'm about my legacy. What's going to happen to what I built? Because I was proud of what I built and what I had and what we stood for in the communities and I had a great name in the communities. I didn't want to sell it to some big national entity who then comes in and changes all the paint colors and essentially rips out everything I put together.
What this became was the opportunity to capture the market and get a great value for what I thought my business was worth, but then to also layout the fact that we could continue our legacy of what we had built. It’s not only to continue but grow it on a larger scale with more help and other people to help us do it essentially. That's what it was for me and how it worked out. With that in mind, we got five other owners and of the five, two of them exited and left out. The three of the other original owner stayed. The three of us then took our cultures, our processes and them all into place and are continuing them. At first it was herding cats to get everybody on the same page, but because we had the same vision of what we wanted to do, it wasn't hard to get the buy-in, if that makes sense.
I understand. Using totally false numbers, let's say I'm a practice owner and I'm considering this and somebody offered me $100,000 on my own. I then think about making this arrangement, and I won't call it a partnership, but this arrangement. How is it that then I get back $200,000 instead of the $100,000? Should I be thinking of it like that?
I think you can think about it like that. I want you to add on after I talk, Sean. I talked to a few brokers as we were going through this process and they shared some generalizations. They'd worked with many PT, mergers and acquisitions and they said, “Your typical practice is going to be maybe around $1 million, maybe $2 million if they're doing well.” That could generate maybe two times multiple of your EBITDA, maybe get a little bit more if the market is hot. If you don't know what EBITDA is, it's an acronym. It's essentially your net profits with some of the add-backs. You can get maybe two times a multiple for a small clinic like that. If your net profit is $100,000, maybe you get $100,000 to $200,000, but if you were to increase that EBITDA to a point where now you're talking to some larger buyers, not just some local dudes, but some national guys who want to plan a national scale, then you can get higher. You can get four times the EBITDA or five times maybe.
I think that's an important distinction to make for your listeners and that is that it's not just gross revenue, but it's EBITDA. The higher it can go, the more there is latitude and a higher multiple for your sale.
Do you want to add anything to that, Sean? What do you think?
It's spot on. Now that I'm on the other side where we're trying to acquire people, you hit it on the head. You're a one or two clinic platform. The two, maybe three multiple off of your EBITDA, the bigger your platform, the more that EBITDA goes up, that valuation goes up. If you're a six, seven clinic, you're probably more four or five. Depending on where you're at and how strong your EBITDA is, that can even go above five. The typical PT practice is probably a three to five EBITDA. It’s what you typically see.To add a lot of value is to essentially work your way out of your business prior to the sale if your goal is to sell it and not work at anymore. Click To Tweet
Sean, I want to come back to something that you said and dig a little bit deeper in them. That is what you said the timing was right. How would a clinic owner figure out if the timing is right?
There are a few factors there. One is where are you in your career with your business? I was taught by our consultants a few years ago that you need to start preparing your business for sale now. I was like, “I'm not selling my business for several years,” but I started to do it anyway because back to my point of listening to them. The stronger you are to position your business for sale and there are things you should do to do that, which maybe should be another podcast, there are some key things there. As far as the market side, what I noticed being in the profession for over fifteen years is the first probably eight years of owning my practice. Nobody was knocking on my door. Nobody was sending me any emails wanting to buy my practice.
All of a sudden, like Nathan said, I started noticing, “We'd like to buy your practice,” or soft reaches, “Will you be interested in selling it?” That's when you started noticing things come around. Then you started getting more and more people hitting you up. It's like selling your house. What's the market doing? Where is the pricing at? We all know when the market is high for selling or house. The PT clinic side was the same thing for me. That was all of a sudden out of the wood where people were coming left and right trying to make offers to come in and made me pause and go, “What's going on here? What is happening?” We can all remember back in these days, but in the ‘90s, the same type of thing that I saw happening in our profession was happening in our profession in the ‘90s. It has its cycles as the housing market does. It was one of those things like, “Here's the cycle and now's an opportunity. If I'm ready to do this and go on and do different things with it, this would be the perfect timing to do it because the market is so hot.” I hope that helps.
It certainly does. I think that your audience will have maybe one office or two. They could be a little bit heartbroken right now to think about that the value of their business is two to three times their net profits and, but what you're showing with your journey, Nathan, is that in “partnering up” with other local independence, your one to two office platform might permutate into a ten, twelve to fourteen-office platform and be much more attractive to a bigger fish. Is that accurate?
For sure. A lot of the value comes off of the numbers. That's how they're going to value the company. You can add value to your company by not increasing the numbers, but they want to see general growth trends. I had done some episodes on this. I did one with Paul Martin. I did another one with Steve Stalzer of 8150 Advisors. One of my first episodes was with John Dearing who works with mergers and acquisitions. There are a number of things you can do to prepare, but they're going to look at the numbers. They want to see good policy and procedures in place.
They want to see growth trends over the last few years. Not stagnation, but continued growth and a strategy for continued growth because they want to know that once you sell, you're not going to walk away. There's going to be a focus on increasing what they're buying so they can increase the value of their investment. Another strong aspect is if the owner's not treating. If the owner owns the company and is not one of the slave laborers within it, then there's some value to that. If they take him out, they're going to have to replace him with someone else. That goes back to structure, policy, procedures, organization and all these things that make a company more valuable without necessarily hitting the bottom line. When you do those things, your bottom line improves.
Back to your question a little bit, maybe they're a little bit disheartened, but I've told a number of people across the country, what we did could be done in other places. If you know any of the other people in your community, some of the other owners, and you're looking at an exit strategy, we called a lot of people. I called a number of friends that weren't ready. They're like, “I don't know what I would do if I would sell.” They're like, “I'm happy with what I'm doing,” or “What is an EBIDTA?” They're across the board. They weren't interested in selling at the time, and that's fine. If you are looking at an exit strategy or if you want to take advantage of the market, start working your network.
Talk to some local people, see if you can get some people who are on the same page and then there are opportunities out there. You reach out to some people who might represent you on the market. Yeah, you can get a little bit more for what you're doing. I know you didn't ask this question Steven, but I would say if you're looking to sell any time in the next few years, now's the time to do it because it's going to go through that cycle again. I don't think it's going to be as hot as it is now. I think we're at the tail end of that cycle, honestly. It's not going to come around for a little while.
Sean, from your perspective, what Nathan did was he got a consortium of local practice owners, probably within 25 to 50 miles of him. Is there any advantage for him to have said, “I'm going to get my pal in Tucson and my pal in Albuquerque and my pal in Colorado Springs. Even though we're not going to have a map or a footprint that's every three to five miles in that geography, I’m placing some pins down in a very large area?” Is that an increased value, a decreased value or a wash from your perspective?
I think it's an increased value from my perspective. When we did our deal, we ended up with clinics in California and one in Louisiana, which is the off beaten path one and kind of weird. The market share, getting it in multiple states is good. I will say some states are more attractive than other states are depending upon reimbursement rates. Is your market dominated by a hospital-based system? We're in the process of acquiring clinics that are states that we are not even looking at it based upon reimbursement rates and the hospital-based systems that we don't even go into. I do want to go back real quick as well and adjust something that Nathan said about selling your business.
I think the key thing to learn is that as owners, we are the goodwill value of the clinic. If you look at selling your business down the road, if you're in the business, working it a lot like say 40, 50, 60 hours a week like we all did some times. You go to sell your business and you're telling the people you're selling it to, “I'm going to sell it to you and I'm walking away,” your business is now less valuable because you are a huge integral part of why the business is successful. Another way to add a lot of value is to essentially work your way out of your business prior to the sale if your goal is to sell it and not work at anymore. That's a key point. The way I got my business is it was running where I didn't have to work in the business unless they want it to where it didn't need me. If I wanted to exit, I could've left and left all the key people who were the key to making the business run. There's more value to that if you want to exit out, if that makes sense.
It certainly makes sense to me and one way you can test your ability to do that is to take a month off. If the prospect of taking a month off makes you want to vomit, then it's likely that you have not put the systems and processes in place to allow you to do that. That's a good stress test.
Yes, there's more value in a business where you can take a month off because you're no longer the goodwill value of that business.
It makes total sense. Nathan, looking back on this process, what would you have done differently?
I don't know. Sean might agree there was an element of timing there. We found a partner and this was something that Sean and Will were definitely a part of as far as they interviewed the interested parties that came through Phoenix. We found a partner that I would say is relatively ideal in allowing Sean and, Matt and Will to carry forth our company values, visions, policy and procedures that we all had some loosely held agreements too and not disrupt that. Empower physical therapy became something that's greater than ourselves and a greater expansive are divisions that we already have. I think I'm speaking for you Sean, but things came together in an opportune way for us to do this because we had a great footprint across Phoenix. We met up with a great partner. We have some great leaders in place. When you talk about Will and Sean and Matt and the CEO that we brought on, there's not a lot I can look at and say, “I would've done things differently.” Things worked out well for us.
You don't think that all the stars were aligned perfectly and it can never happen again. This situation can be repeatable across the country with other practice owners.
I would think so. The benefit that we had was that Jared had been through this process before. The guy, Jared Bowman, who started this ball rolling, he knew the landscape well. He also knew the people to talk to. We did have that in our favor that other people might not have. Anyone that puts forth a little bit of effort and takes the banner and runs with it could do the same.
I would agree. It does take a little work. Jared was a huge help because he understands the business acquisition side and understands the power of the equity world better than we did. That was where our strong play was. You would need someone like that, but that's what you definitely could do. What was different about us is that in the beginning, Nate mentioned it and I said it too, people were approaching us to buy our business. What we did that was different was we came together and then we started approaching the private equity firms and shopping them.
What we realized is that there were people were approaching us whom I'll never sell my business to them. We're like, “Let's find somebody who understands our vision and what we want to do and is excited about it.” We went through that process, which was close to over 30 PT firms that we reached out to interview about ten of them in person. We ended up finding the group that we went with that loved our story and loved what we wanted to do as a profession and was totally on board, so it definitely can be done.When you do things that add value, your bottom line improves. Click To Tweet
You’ve brought up a good point there, that maybe we didn't iterate it, but we had an ideal partner in mind. If we're going to exit and we're going to sell our legacy to someone else, this is what they're going to look like and this is how they're going to be. It's not necessarily the best idea to take the highest bidder. It's valuable before you sell to number one, maybe have an idea of the number that you want, but also number two, who do you want to partner with? You want to vet that because that's going to affect your life significantly going forward. You want to make sure you've got the right person with shared alignments in values, vision, growth strategies and whatnot. You want to make sure that you're partnering up with the right person or group.
There's a lot of due diligence that needs to be done. There’s no doubt about it. Sean, where can our audience contact you? Hopefully from this show, people have a lot more questions now than they did before work. Where do they contact you if they had additional questions for you?
They could always reach out to me in my email. It’s SMiller@EmpowerPT.com. I love helping people and I love showing people what to do and what I've learned from it. I'm a big believer that we're always growing and learning. I've always said, I'm the biggest rip off artist there is. I steal from other people what they've done and implemented it. If that works, I'm going to do that. It’s not to say, “Come steal from me,” but come steal from me. I'd love to share with things that people are interested in trying to do this or what we did and I’ll be more than happy to take time and talk to and discuss it with them about it.
Going back to what you were asking me about me, Steve, if other owners can do that nowadays what we did, go ahead and try it. Reach out to Sean and say, “I'm thinking about doing this. What are some tips that you have?” Reach out to the guys at Empower PT that did it. We can guide you. If you're looking to sell, Empower PT’s a great place to go. I'll put in a plug right now.
I've got to say the same thing. If you are looking to sell, we are still looking. We are trying to expand and grow and we have a huge vision belief behind therapists. Our core value is patients first. We’re a PT-centered company focused on the profession, trying to enhance the profession. We're looking for people with that same mindset that want to help us continue that vision out to the public. Come talk to us. We're always open to that as well.
Sean, I want to thank you for your time and your expertise. Nathan, I want to thank you for being on your own show. That's very nice of you to show up. I'm sure it'll be an interesting listen for yourself and your family and all your friends. I encourage everybody to tune in for every episode because there is a lot to learn. Nathan is spouting out truth bombs left and right and we're all the better for it and everybody in the profession thanks you for it. Thanks again for your time.
Thank you, Steve.
Thanks for having me.
I think it was great to do this little forum. A lot of people could learn from what we did and if they wanted to reach out to us personally and bounce some ideas off of us or ask for some insight or maybe you can help me with this, feel free to do that, whether it's Sean or me, it’s Nathan@PTOClub.com. By all means, reach out. Steve, thanks for offering to do this and I'm excited that we got the opportunity to sit down and do it.
All good things happen when you shoot from the hip and have no script and let it rip. You guys are very good sports and, we came up with something good, don't you?
Definitely, thank you so much, Steve.
Enjoy the rest of your day and thanks.
Thanks for your time.
Stephen Rapposelli, PT, OCS opened his private practice in 1992 at the tender age of 26, because he was told by his previous employer that he couldn't buy into the existing business. He has since grown into 3 clinics and has been voted best PT business in his state for numerous years. H
e also serves as Vice President of the Delaware PT Association, as well as sitting on the IMPACT editorial board. Stephen plans on devoting the rest of his career to promoting independent practices across the country.
Growing up Sean always felt the desire to make an impact in others life. It was in high school when a friend got hurt playing sports that Sean was introduced to the power of physical therapy and the impact it has on people’s lives. From that experience, Sean has set a course in his life to be a Physical Therapist and change lives. Receiving his Bachelors of Science from Brigham Young University in 1999, Sean then pursued his dream of getting his education in Physical Therapy. In 2001 Sean graduated from Texas Woman’s University in Dallas, Texas. Moving to Arizona in 2002 working for others Sean became very proficient as a Physical Therapist.
He now specializes in treating vertigo, balance, and orthopedic cases involving the shoulders, cervical (neck), and knees. After years of treating patients, full-time Sean realized that he was just 1 Physical Therapist and only had the ability to treat so many patients at one time; It was this realization that sparked the dream of owning his own practice. “What if we had multiple therapists all with the same skill and passion? The impact would be even bigger than just 1 therapist”. From this Sean along with his brothers opened Kinect Physical Therapy in 2012. “Opening Kinect Physical Therapy has been one of my greatest challenges, but to see the larger impact we have on the communities and in our patients is why I do this.”
Sean when not making an impact on others life’s enjoys spending his time with his wife and their 4 children. He is often found on the sporting fields coaching his boys teams, at the lake wake surfing or headed to the beach to enjoy the waves and surfing. His favorite quote that he lives by is: “We are what we repeatedly do, excellence therefore is not an act but a habit.” – Aristotle.
Love the show? Subscribe, rate, review, and share!
On this episode, I'm lucky enough to bring back Heidi Jannenga of WebPT. She joined us before and we discussed the State of Rehab Therapy that WebPT does every year. We're bringing her back again because the new State of Rehab Therapy Survey and Report is out again and you can get that at WebPT. Heidi and I sat down to discuss some of the takeaways that she took away from this year's survey. It's a little bit dark on the front or maybe not dark, but somewhat discouraging. We talk a little bit about the burnout issue that is in physical therapy and what might be leading to that. There's still a large amount of student debt out there that the new grads are coming out with and salaries haven't changed all that much and yet reimbursement rates are declining. We talked a little bit about that and we also talked about some of the greater opportunities that are out there for physical therapy as well.
We see a lot of consolidation that could lend it to greater reimbursement rates, as some of those companies are starting to negotiate with insurance companies and gathering their data and outcomes. Also, from what I can see as a possibility that those larger corporations are willing to invest in greater benefits for physical therapists and invest into the cultures that they're creating. There's a further opportunity out there and the needle hasn't changed much in that 90% of the people that need musculoskeletal care are not getting it from physical therapists. In spite of the fact that all 50 states have direct access, still eight out of ten providers are reporting that insurance limitations or their perceived insurance limitations are a barrier for patients to get physical therapy. Simply, it's important that we educate ourselves and start acting like the forerunners and the gatekeepers of musculoskeletal injury.
There's an opportunity to communicate with the public and be on the front lines and not waiting for the referrals. There's an opportunity in regards to the burnout and whatnot. It's an opportunity for you as the owner to sit back and say, “What am I creating here that would make my culture such that people want to stay, that would keep them engaged? How can I align purposes or find people that are aligned with me and our purpose as a company?” To work together as a team, develop a culture max out of the customer experience and make it enjoyable for them and thus, that makes it enjoyable for the patient. There are a lot of opportunities there even though we see some negative signs that came up from the report, but there are also some positive signs and we go into that a little bit.
Heidi is a busy person. I'd love to spend a little bit more time on what WebPT specifically is doing to overcome some of the challenges that physical therapists have in regard to the amount of time it takes to do documentation. Also, to address the regulations that are upon the physical therapy providers themselves on a day-to-day basis. Nevertheless, I'm sure that will come up in WebPT’s business conference called Ascend 2019 in Minneapolis on September 19th to 21st. Check out their website. I’m sure if you Google Ascend WebPT 2019, you’ll get all the information that you need and if you mention that you are a reader of the blog, you will be able to get a discount. Check that out and put it on your calendar. It's one of my mantras, “Step out, reach out, network.” This is an opportunity to network, get some business training, see what's happening out there in the industry and network with other successful physical therapy clinic owners. It will be a great opportunity for you to learn and network and feel like you're not alone in this. Let's cut to the chase and we'll get right to the interview with Heidi.
I've got Heidi Jannenga of WebPT. She's always very busy so I'm excited to bring her on. Heidi, thanks for taking the time to spend a little bit of time with us and talk about The State of Rehab Therapy.
It's honestly my pleasure. We have lots of interesting things that have happened over the year and I'm anxious to share a little bit about some of our new findings that we had from our 2019 State of the Rehab Therapy Industry Survey. I'm excited to be here. Thanks for the opportunity.
It's great that you guys have done this survey and I think this is the third year running, if I'm not mistaken. Looking over it, the amount of data information from it is interesting because I don't see a lot of this data coming forward from other parties and sharing such a broad perspective of The State of Rehab in general. First of all, thank you for doing it because I think it provides a lot of great insight into the profession for all of the professionals. What was your impetus for doing it in the first place?What we don't want to do in PT is lose the best and brightest minds coming into this amazing profession. Click To Tweet
That exactly was the impetus that when we went out looking for data, we couldn't find it. At WebPT, our mission has always been to help therapists achieve greatness in practice. To be able to truly do that effectively, we need to understand the lay of the land, like what is happening and getting direct feedback from therapists themselves. In order to understand the state of our profession, we wanted to be able to see sweeping industry trends. We wanted to understand more about how people are treated and what barriers they're encountering nationwide. We decided to embark on our own survey and we started it. Every year, we've gotten more and more people to be able to give us feedback and take the survey.
Each year, we've dived into a little bit more information based on what we received the previous years. To be able to compare, we ask a lot of the same questions as well. We divided everything up into four categories first of all, which I think is important as you look through the survey. We dove into things like payer mix and therapist productivity, referral sources, utilization of direct access, market consolidation, provider burnout, technology use, growth strategies and salary. A lot of the top of mind things that people are asking about. We get lots of questions around these things that we wanted to have interesting information directly from the sources which we frankly couldn't find elsewhere. We said, “No one else is doing it, we're going to do it.”
You found a hole in the market that was needing to be filled. How has it changed in the last few years? Is there some data that you found that's most valuable now that you didn't expect back before? What are some of the things you're noticing in the information that you want to collect?
We had about 6,500 unique responses to the survey. Just for clarification, 53.2% of those were not WebPT members. This is a clear, very diverse population of respondents and definitely not biased by whether or not they're using WebPT. At the end of the day, 90% of our questions had nothing to do with technology or EMR usage, although we did ask a little bit about that because it's important to us. About 63% of the respondents were therapists. We also had rehab therapy assistants, so 8.5%. The rest were classified as non-clinical, whether that's an executive, a clerical worker or a student. About just shy of 50% of the survey takers were also in outpatient private practice, which we also liked. It gave us a diverse cross-section into the entire industry, not just outpatient where some of us live and breathe most of the time.
Some of the things in the past that have been thought-provoking around salaries and student debt were asked. Despite our information being spread and wide and the American Physical Therapy Association does a great job of making this an important issue, the needle has not moved that much yet in terms of the amount of student debt that students are carrying these days. We might have talked about before that the average is about $70,000 in debt when a therapist graduates from PT school and close to 35% will have over $100,000 or more in debt. You compare that to the average salary is about $65,000 coming out of school. The question mark becomes, “Is the juice worth the squeeze? Am I getting into something that I'm going to be in debt for a long time to be able to pay off those $100,000-plus in debt?” There are also the sentiments of burnouts that we captured quite a bit in the survey.
Is that something that came up? I don't remember it last time the burnout that you're recognizing.
We added that. We now ask very specific questions about burnouts and thoughts about leaving the profession based on the feedback and also the data that we received in 2018. The survey continues to evolve based on information that we're getting and wanting to learn more about the industry as a whole. That was unfortunate but also an important data point. About half the survey respondents are considering a profession change in the next five years and one in five of those respondents would like to move into a non-clinical role.
Some of the reasons that people were giving for that are the immense compliance and regulatory burdens that t they feel like they have to endure and not at the end of the day, why you and I got into this profession. I didn't want to have to fill things out in triplicate and have to substantiate everything that I specifically need to do three times over before I get approved for it. We're getting squeezed on a number of visits. We continue to get reimbursement changes that happen. It's harder and harder to be a physical therapist who wants to affect change and treat patients.
I've noticed the burnout thing a little bit more recently. Someone said you look around our profession, you don't see a lot of 60, 70-year-old physical therapists that are practicing at full-time and loving it, just like you might see a family practice doctor or a general dentist or someone like that who it goes to work every day and loves their job. You don't see that a lot in the physical therapy profession. I don't have any data behind it and maybe you guys do, but there seems to be the burnout, the constant focus on production now that reimbursement rates are declining and the regulatory issues that are on top of us to stay in line. All that squeeze makes you question whether or not it's worth it and that makes it difficult.
The burnout is becoming earlier. In general, we age out because we have such a physical job as a physical therapist. It's in our name. Whether it's transferred or whether it's manual therapy, it's a very physical job. You're getting down and showing people exercises every day. It's not conducive to be doing that into necessarily your 70s. I don't know that's really changed so much. It’s in terms of the earlier burnout and also seeking other professional tracks as a physical therapist, not just being held to, “I'm going to be in clinical care for the rest of my career,” which I thought was interesting. For me, having taken a completely different path outside of clinical care, what I don't want to do and what we also have seen is that there is a decline in students applying to PT schools. Now, the outcome of after PT school and that burden, things like that are starting to become issues to even getting recruits into PT school. What we don't want to do is lose the best and brightest minds coming into this amazing profession.
At the same time, once they're in and once they are starting into clinical care and they find out, “Maybe this isn't necessarily what I thought it was going to be.” We need people to stay in clinical care, that's why we become a physical therapist. I also love the fact that some of the smart and brightest people are doing things representing the physical therapy profession in other ways, whether it's technology, whether it's entrepreneurship, whether it's going into public health or whether it's going into hospital administration. To demonstrate that our profession has a lot of very diverse but brilliant people that are not just ancillary providers. I see it on both sides that it's not great that we have the potential to lose clinicians that can help people and continue to improve the overall brand of who we are. I think that brand can also be accelerated by having more therapists exploiting the value of rehab therapy and PT in different arenas that we're not represented in now.
I interviewed somebody like that, David Self of Keet Health. He was the guy that went through PT school and never treated patients but rather developed his PRM program. It's people like that that you can hopefully say, “There is a track for physical therapy to treat patients and whatever, but there are also other tracks outside of it that can lead you to promising careers as well.” It's tough when you see on some of the social media posts and maybe you've seen them. I've seen them as well. People are saying, “I'm doing this and that and I'm interested in getting to physical therapy. Is it worth it?” I see, just looking forward, some of the respondents are very positive, “It's a great profession.” Some are very negative, “No, it's not worth it. It's tough.” Nowadays with the social media and the capability of people to reach out ahead of time and talk to larger audiences, it's tough if people aren't happy in their positions inviting those bright people into the profession.
There's whole track now of non-clinical PT rise even on social media. Meredith Castin leads a whole podcast and blog post and a group of non-clinical PTs, which I don't necessarily see as a bad thing. They are promoting the profession of physical therapy in such a fantastic way that sometimes I think clinicians who are treating patients all day don't have the opportunity to do. There are a lot of opportunities there but to your point, those that are in clinical care and those that we need to continue to have a pipeline of more amazing clinicians that want to do clinical care. Even those that are getting to the horizon of their career have said that, “I am not as readily willing to tell people, ‘You should become a physical therapist anymore.’” That's the sad part because usually your evangelist of people who love what they do are willing to tell more people and get people excited about the profession.
Did you find that through the survey, some of your hallmark findings were led into the burnout that we're talking about, whether it's some of the challenges that came up consistently that led to the possibility of some of this burnout?The PT profession has a lot of very diverse but brilliant people that are not just ancillary providers. Click To Tweet
The regulatory change, the number of hours that people are working. Of those respondents who I mentioned who are considering a professional change, about one in four of them are doing to decrease the hours that they have to work. I thought that was very interesting. Whether that's based on working more than 40-plus hours in order to make ends meet, you're working your regular full-time job, but you're also doing PRN work on the weekends and things like that. I did that when I was coming out of PT school as well. I don't think that's anything new. In this next generation, work-life balances are even more strongly emphasized and wanting that a component of their life. I think that's reflective of this next generation’s expectations of their professional life. The other thing I would say and part of the reason that we publish this information is for people to use it and take the data and say, “What could I do differently?”
As new grads coming out, they're looking for a great culture in clinics. They're looking for a career passing and mentorship. They're looking to learn. There are a lot of therapists, whether you're new or not, that are wanting those things. As we get busier and busier, sometimes it's hard to find that balance or those great cultures. For leaders to be spending time and money, the bottom lines are not what they used to be. The additional ability to spend more money on benefits and things like that is not as easy, but it's also important. That is a good segue into what we see as far as consolidation in the market. It's been the pendulum that has swung back a little bit through my career.
When I first came out of PT school many years ago, it was very dominated by “corporate PT organizations.” We had the dissolving of a lot of those organizations due to corruption, the Medicare fraud. We saw the rise of entrepreneurship. With that, we see the opportunity now. Private equity money floats into our industry several years ago and now we're seeing the cause and effect of that with many medium-sized organizations being on the quest to grow. I don't always think that's a bad thing. There is a lot to say about economies of scale. I think that people have learned a lot from the past and how they want to do things. There's technology now that helps to make more of the communication and centers run more efficiently. We did see in our survey that larger organizations do have a higher patient volume requirement.
About 40% of our full-time therapists in single providers see six or fewer patients a day, which if you're seeing cash-based patients, I could see that. Still, that's a very small number overall. In organizations with 21 or more full-time providers, they're seeing about nine to twelve patients a day. If you have twenty-plus providers, your patient load can increase from twelve to fifteen patients per day. I think corporate organizations or these large entities get a lot of bad rep for having to churn and burn and see tens of patients a day. Twelve to fifteen patients didn't seem at outrageous to me or outrageous at all to me. I think that there has been a tide change in terms of being more efficient operationally and yet still being able to give great quality care with also that emphasis on outcomes.
You talked about the swing towards more, if you could say corporate care or consolidation. The benefits definitely could be these entities having greater funds, the economies of scale in which they can reinvest into a culture where they can reinvest into providing greater benefits that the entrepreneurs might not be able to provide. Also, coming back to having a seat at the table with the insurance payers to renegotiate those contracts and bring reimbursement rates up. Even though some people might hate to see that coming down the horizon and more mergers and acquisitions occurring, you can see some benefits on one end when they might be willing to reinvest if they're willing and able to do so with maybe a little bit but still maintain high productivity. I think there might be a little give and take on that.
I think one of the downfalls in the past, which we've learned from was that these large organizations try to undercut each other to increase the volume of patients by decreasing the amount that they were willing to take per visit. You don't see that as much. Insurance companies have already done that for themselves because now they also have a lot of data of what they're willing to pay. What we are starting to see and it's low, only 17%, 18% of organizations that collect outcomes data are using it to negotiate with payer contracts. The majority of those are the larger organizations, but they're using those outcomes to increase their payment adjustments, not trying to undercut.
Insurance companies have already that for us because of what we were willing to take in the past. Now, we're negotiating to increase. If I'm going to get better outcomes in improved utilization and less visits, overall that the insurance company pays less, even though the price per visit is higher.” That's the negotiation that's starting to happen now with data. To be honest, that's what it’s all about now. Being able to prove with hard facts and clinical outcome data as well as utilization data, patient-reported outcomes but also patient satisfaction scores as well as the trifecta. What we've talked about in the past of what everybody's focusing on, making sure the patient’s happy, make sure the providers doing what they're saying they're going to be doing and also being cost-effective at doing that.
You talked about some of the things that can link to upset for a provider, whether that's regulations and student debt and satisfaction in the profession. Are there some things that you recognize are challenges within the care of treatments that therapists are regularly reporting? Whether that's pressure from supervisors for production or the documentation time that it takes to get a patient through or time away from patients that don't make them? Are there some of those things that came up?
Those are all part of the challenges and opportunities. The things that we found were most concerning to therapists that were within this policy and regulation area where high co-pays and co-insurances, referrals and certification requirements, then the therapy thresholds or targeted medical review thresholds given by insurance companies. The autonomy of practice is not what it used to be. The burden of the high co-pays and co-insurance is now the pressure to show value and have patient buy-in becomes so much greater because there's so much more out of pocket costs.
That's tough when a physical therapist has to have that financial conversation. It's something that's come on over time, especially in the last several years or so. I didn't have to have those conversations as much earlier on, but it's almost regular now that you see that the patients are having to have some conversation regarding the financial responsibilities of the patient have and displaying the value that we provide as physical therapists. That can be tough for people who aren't used to that situation.
This goes to a bit of a crack in the foundation of ourselves as professionals in terms of the brand of physical therapists in the first place. Of people understanding the doctorate level professionals that they're seeing. That your average consumer understands the education and the value that a physical therapist can deliver but not only that, just the fact that we should be the first provider that people are thinking about for musculoskeletal injury. That's another good segue into one of the biggest items that I'm going to be talking a lot about and have talked about, but emphasizing it now is the direct access issue.
We have now direct access in all 50 states. We have that now. It's not new. Some states like Arizona, where I'm from, we have completely unrestricted access and we've had it for more than twenty years. Yet people are still very intimidated by the ability to take someone off the street, walk into your clinic and have them get treated without a physician referral. The confidence in ourselves as therapists has to be promoted. I don't know how we get past the change in behavior. We have the knowledge and we have the skillset. It puts us in this incredible driver's seat of more level-playing fields with referring physicians because now we become a referring provider as well. Especially in states where you have some limited access where you can only see them for an initial eval and/or maybe a couple of visits or even just the initial eval, let's take the Medicare. To be able to then send that back to a physician and say, “Patient came in. This is what I found. Here are some issues that you might want to look at. Here's how I can help this patient as a physical therapist. You go do your workup and then I'd love to see them back to help them with the issue that they came in with.” Now you become a much higher prominence, if you will in the overall healthcare continuum where people see you as more of an equal.
Where do you think our hesitancy or fear to take the reins in those situations comes from? Is it just from a longstanding history of being, for lack of a better word off the top of my head, subservient to the other medical professionals? Are we not getting proper training beforehand in our schooling? Where do you think that comes from?
Let's face it, we're still a fledgling profession in terms of the grand scheme of things. Where we started was being subservient to physicians and having to rely on referrals from the get-go. It's the longstanding behavior that you have known for most of your career and I don't think that referrals should go away 100%, but I think that it should be a 50/50 split in your clinic. It's going to take a lot from not only ourselves of being willing to take these patients in, which I think is the first stage. Secondly, doing a lot more promotion and education to the consumer as to the value that we deliver and who were good at helping. I will say that I truly believe that the time is now to be 100% emphasizing this. This is why this is my biggest soapbox because of the opioid crisis.In this next generation, work-life balance is even more strongly emphasized as a component of life. Click To Tweet
We know that insurance companies, hospitals and everybody are focused and this is at the highest level of administration of all of these different entities of finding, even at the state level. I was listening to NPR and even in our state level, the top of the conversation in every healthcare arena right now. A significant percentage of the patients that have been given opioids suffer from chronic pain and musculoskeletal pain. Who else is better to be treating these patients for musculoskeletal issues? It's us as therapists. There was a big study that was published by the American Physical Therapy Association and OptumLabs and UnitedHealthcare in which UnitedHealthcare finally came out and said, “We've had this data for a while but now because of this crisis, we understand that physical therapists need to be a primary provider. We need to get them in earlier as an intervention provider for these patients that come in with musculoskeletal issues, specifically low back pain.”
They published in their study that if a physical therapist or I should say conservative care provider, so that includes chiropractic or massage therapy, is the provider that the patient is seen for in the early stages or more acute stages of their injury, they have a 75% to 90% chance that they will never encounter opioids through their episode of care. The data is there to show our value. We just need to scream from the rooftops. I keep threatening that and maybe I should do it. Get a crowdfunding thing to do a Super Bowl commercial or something to make this a known thing, who we are as physical therapists and what we do and how much value we can add to patient's lives.
My next question is part of it is communicating to the public and some of the other healthcare individuals, but how do we change within to have the confidence to stand up and say that we are the masters of musculoskeletal injury care? We are the first line of defense. We are the gatekeepers or whatever you want to call it. It doesn't seem like we've taken that upon our shoulders to be that. From your perspective, what needs to happen? What do we need to do?
First, it comes back to education. Although we've had direct access in all 50 states for quite a long time, in our survey we found that only 13.5% of respondents said patients could directly access PT in their state.
They didn't know.
It baffles me that they don't know, but they don't know. 80% of the organizations said that they still require a physician referral for treatment. Roughly eight in ten respondents claim that payers are the top reasons why. We know that that's not true. It’s a lack of education and lack of understanding of the changes that have happened. Most insurance companies now will allow at least the initial evaluation. If your state practice act says you can see them unrestricted for more visits, it may not be the case based on insurance, but the majority of insurance companies now will pay for an initial evaluation, even Medicare, which is always the one red flag that people throw. The biggest barriers to direct access in which it is perceived are insurance requirements and then the lack of awareness in the patient market. There are not that many patients walking in the door.
This is where this movement for patient retention management, more marketing to the consumer, more of a change in mindset that we are a consumer-facing provider and not just a B2B or a physician to therapist provider where all of your targets in the past and marketing efforts have been much more in terms of getting to know your physicians. Now there's this change, which I'm hoping becomes more of a tidal wave of understanding that we need to go directly to the consumer and get these people to understand that, “You can come in and see me. Here's who I am, I'm an amazing therapist. I can help you in so many different ways.” We just got to get them into the clinic.
Being an owner in the past and I'm assuming that probably a majority of your respondents not only coming from outpatient settings but if they are owners, they've probably been owners for a longer period of time. I'm making a couple of assumptions there.
Only 50% of our respondents were outpatient. It is the broad spectrum of respondents.
From my personal experiences is that you hear that, but you're not sure if you trust it enough to change policy inside the clinic and risk losing so many visits on some patients by not getting that referral or getting the prescription ahead of time. I think it's constant education that needs to be consistently reinforced and then taking action and dipping your foot in the water a little bit more and saying, “It's okay. Come on into the pool. It's all right.” It's a lot of education and showing proof of concept to these people that you don't have to have some of these things. You can be the gatekeeper, you can stand up and you can be the person at the forefront and not need what was needed in the past. That can be difficult when you said we need to shout it from the rooftops in order to get the message across.
Change is always difficult. If you don't have a cash pay schedule now, you need to make one and what do I charge? There's the fear of, “I don't want to charge too much.” All of those unfortunately things that our clinician brain takes over versus the business brain. When we know that people are willing to pay $100 an hour for a personal trainer, why wouldn't they and why shouldn't they pay that for a doctor-level professional who is going to do so much more for them than supervise and provide an exercise program? It's also the mindset and when you said, “How do we make changes?” It does go back to student education in our academic setting of priming the pump early. The confidence in who we are as therapists have to come from the education first and truly believing that this is the norm. This is what you should expect when you go out and if you don't see this, how do you help to make that change as well?
It's a tactic that we've used even from a technology perspective. Introducing electronic health record and electronic medical record in the academic setting and having students use it. When they go out to their clinicals or even when they go out for their first jobs, to then see something that is much less efficient, not as user-friendly or pen and paper, that they are willing to raise their hand and say, “Have you ever tried this? Why are we doing it this way?” It’s the old adage of asking why.
A lot of it is education. Do you see anything else that we need in our tool belt to become more of the front-line defense? Not just to let therapists know that they can be, but from my perspective and because I'm a little bit biased, I'm doing more diagnostics. I do EMGs and I have also been trained in musculoskeletal ultrasound. Do you see diagnostics being a big part of being recognized as that first line of defense for musculoskeletal injuries?
Of course, we have a shortage of primary care physicians. Pushing that line of the scope of practice with these additional certifications and aligning with physicians who are willing to have that information and refer you patients to get that information or that data I think is important. Also, going straight to a patient. The patients’ potential population out there to have them understand, “These are our certifications and value-add activities that we do as physical therapists. It’s part of our scope of practice. It's part of who we are and what we do.” This goes back to the part of our big purpose and mission here at WebPT in the data that we've found and validated with a lot of insurance data as well is that 90% of patients who have diagnoses that a physical therapist could help are not getting into physical therapy. We're fighting over this 10% of people and that number hasn't grown. It comes back to what a lot of people have been talking about for the last several years of the brand of physical therapists.Physical therapists need to be a primary provider and an intervention provider for patients with musculoskeletal issues. Click To Tweet
Tell me what is WebPT working on to help alleviate some of the concerns we talked about or some of the exciting things that are coming forward that WebPT is working on that you'd like to share?
We're continuing to work on efficiency. It's been one of our big mantras here. We’re starting to release our WebPT Documentation 2.0, which has a full new look and feel, but more importantly, much more efficient in terms of getting through your documentation. We're using the data from this survey to make sure that we're hitting all the marks on the biggest barriers. We are working on what we're calling WebPT’s network effect of now working with credit card processing as well as with our outcomes tools. Getting that data and information out there through an analytics platform that can help and empower our clinicians and our owners to use the data. Go and negotiate more with insurance companies to increase those reimbursements or payments that they should be getting.
From the marketing front, we're continuing to improve our PRM or Patient Retention Management platform in which we have so many cool new ways of increasing your HEP, your Home Exercise Program compliance, as well as retaining patients so that you have this constant communication them. Our big thing with that is to hit that 90%, to get more of the marketing component out there. Not only to retain the patients who have come to see you, but how do you increase that by social media likes and email and everything else that you can do to get your clinic more notoriety.
You talked a little bit about analytics and that was always something that I always wanted more for my EMRs, the management statistics so I can have more access to that. Even if it's not for going out and renegotiating contracts, that's a great end goal. Just to manage the day-to-day and make sure that you didn't have holes in your bucket and you could manage it appropriately and manage it by statistics. That's exciting stuff.
We have a whole dashboard of the top nine clinic metrics. You can watch it. All about efficiency where you don't have to do a bunch of spreadsheets and have all this backend work. The data's already in our EMR so how do we then aggregate that and allow you to use that on a day-to-day basis to run your business at the highest efficiency?
That's where the independent practitioner is going to be benefited the most by an EMR like WebPT. Being able to have that as a dashboard and not go looking for it and spend the time on it and thus manage their clinics. Though we're not trained as businessmen, we own businesses. Even though we're not trained as such, it's important that we have those KPIs available to us on a regular basis and managing them and tracking them, even though that's maybe not our forte. It’s exciting that WebPT has that available to us to help us manage appropriately and thus capture what we're supposed to be getting paid for. Like we talked about, maybe reinvesting in culture, reinvesting in benefits and making it a wonderful place for physical therapists to join and be a part of.
This is an area, especially for your small businesses and single provider owners who are wanting to grow or are wanting to make their business more efficient. We have heard you because this is an area that we don't come out of school knowing a lot about, is the business side of physical therapy. What are the KPIs I should be looking at? How do I take those KPIs and make sense to them? What do I do when it goes down? What are the dials that I need to look at to be able to improve those numbers? That's also why we started our annual rehab therapy business summit which is called Ascend. We've been doing this now for years. This 2019, it’s going to be on September 19th through the 21st in Minneapolis, Minnesota. We would love to have you guys come out. If you come to the website and decide to sign up, please let us know that you came from the Physical Therapy Owner's Club show and we'll make sure that we get you a discount code.
Thank you for doing that. I, number one, love the idea that you've got the Ascend conference going and that it's focused on the business aspects, especially like what you talked about. We come out of school, we don't know some of these things and then you hear about, “You need to keep your KPIs.” “I can start keeping my KPIs.” As you said, when they go down, now what? I'm reading the WebPT dashboard that I have and my stats aren't where I want them to be. What do I do? That's where a conference is so invaluable. The networking can be incredible. My mantra is step out, reach out and network. This is how you network. This is how you get information from the other successful business owners. This is how you learn successful actions and take advantage of those who have gone before so you're not reinventing the wheel. It's conferences like this where you'll gain a ton of information and get some of your business acumens.
You learn from people from similar-sized practices to larger practices. We've got speakers from all over the country, the best and brightest minds that we can pull in for an event like this. We’ve got some amazing keynotes from outside of the industry, which we also are big promoters of, to learn from people outside the industry. It's going to be an amazing two full days of super content and lots and lots of learning. Most importantly, lots of networking. We have a lot of time for that very specifically because we know how valuable that can be. Hopefully, we'll see you there. Let us know if you've found us on here and we'll make sure we give a good discount.
Thanks for your time, Heidi. I appreciate your willingness to talk to us, especially about the insight that WebPT has gained from the state of the industry.
You're very welcome, Nathan. Thank you for all that you're doing for the therapy owners out there. The more education that we can get on this business side and more people working together towards the greater cause of helping our profession only makes us stronger. Thank you for everything that you're doing for the industry as well.
Dr. Heidi Jannenga, PT, DPT, ATC, is the President and Co-Founder of WebPT, a six-time Inc. 5000 honoree and the market-leading software solution for outpatient physical, occupational, and speech therapists. Heidi leads WebPT’s product vision and company culture initiatives while advocating for the rehab therapy profession on a national scale. She's an APTA member, belonging to both the private practice and sports medicine sections, and she's on the board of directors for the Institute for Private Practice Physical Therapy.
In 2015, she won the Arizona Physical Therapy Association’s Physical Therapist of the Year Award, and in 2018, she received the APTA’s Marilyn Moffat Leadership Award. Prior to co-founding WebPT, Heidi practiced as a physical therapist for more than 15 years. Today, she regularly speaks as a subject-matter expert at regional, national and international technology, entrepreneurship, and leadership events, as well as at national and international PT industry conferences.
Heidi serves on the boards of numerous organizations, including the Arizona Science Center, Support My Club, the Physical Therapy Political Action Committee (PT-PAC), the Institute for Private Practice Physical Therapy, Conscious Capitalism AZ Chapter, and the Arizona Community Foundation. She also dedicates time to mentorship within WebPT (through her women’s empowerment group PropelHer) and in the broader community (through her work with physical therapy students, entrepreneurs, and women in business).
I have a guest by the name of Brian Weidner of Career Tree Network. Brian and his company have been recruiting physical therapists for over a decade now. He's the President and Founder of Career Tree Network and is based in Milwaukee, Wisconsin. Since 2007, Brian has helped thousands of physical therapists achieve their goals within new positions. Thus, I wanted to bring him on and see what he can share with us, some of the secrets that he has to recruiting physical therapists. I know many of my colleagues have had a difficult time getting physical therapists especially qualified physical therapist in the door. To some extent maybe they've been able to overcome that by utilizing traveling physical therapists or students quite a bit. Making sure they come through on their internships and thus hiring them.
Many people might not have that option, especially in smaller clinics. I thought it'd be valuable to bring on Brian to see what else we can do to recruit physical therapists on our team and not only bring them on when we need them, but also have some sitting on the bench waiting to join our businesses. It's a possibility. I know my partner, Will Humphreys, is great at doing that with our clinics in Arizona. Built a nice solid bench of therapists who simply said, "When you guys have an opening, let us know." It can happen. Brian shares with us his secrets to the ads you should write, what you should be saying. Other things you can do besides simply posting online. Shares with us these things throughout the interview. He was also kind enough to share with us a PDF of some of the talking points that we have. He's happy to share his insights. He can even share with you that PDF if you want to contact him through CareerTreeNetwork.com or HireAPhysicalTherapist.com. Nonetheless, if you don't want the PDF, then read the blog and take some notes.
I've got Brian Weidner, the President and Founder of Career Tree Network joining me to talk about recruiting. A very common pain point for a lot of physical therapy owners is recruiting your next physical therapists specifically. I've talked with a number of guests in the past about recruiting in general. The insight that we've gained from past episodes like Jamey Schrier or Dr. Sabrina Starling. They've given us some good advice on recruiting talent and whatnot. Sometimes there's difficulty in getting a physical therapist on board with you. I have Brian Weidner of Career Tree Network to help us talk through that a little bit. First of all, thanks for coming on with me, Brian.
Thanks so much. I appreciate you having me on. I'm excited about our conversation.
If you don't mind, Brian, if you could share with us a little bit about where you're coming from, what got you into the PT space altogether and a little bit about your company?
My wife is a physical therapist. Back in 2004, she was graduating from PT school and we are moving to Milwaukee. We were both looking for jobs at about the same time as part of that transition. She sent out her résumé and instantly gets a phone call back from the recruiter trying to set up a phone interview. I would send out my résumé and wouldn't hear anything in response. Not that I'm a bad guy or a poor candidate, but the need for PTs at that time was pretty significant. Thankfully for both PTs and recruiters and marketers like me, there's still a big need for PTs. At that point, I had seen that there's a business here to help other healthcare organizations with their advertising and their attraction of PTs to their organizations. Since they're contacting Heidi right away, they must be herding for staff to come and join their team.The best candidates are those who are not going to be concerned with salary. Click To Tweet
You decided to create Career Tree Network because you saw that. Are you pretty much focused on physical therapists?
In 2018, 92% of our projects were for PTs. The remaining were for OTs. We do speech therapists as well. For some clients, we've done like nurses, office managers and rehab aides. PT is our primary focus.
We want to talk about what to do, how to help that physical therapy owner who's stuck. They've had the ad out there. They're working their networks. They're on all the social media saying that they're hiring, but they can't get that physical therapy résumé across the desk in order to simply interview them. What advice and what experience do you guys have in working that out?
The biggest pain point is when you've had the job posted and advertised for a few months and you're not getting much response. First off would be to take a look at the actual job advertisement that's being used. A lot of times the advertisement is written from the perspective of a physical therapy owner. Often they're writing things in the ad. For example, we might say, "I'm looking for the best and the brightest physical therapists to come and join our team. They need to be motivated. They need to be at the top of their class. They need to be this, that, and the other." First off, when we write the job advertisement, there are certain things that we would do from a screening perspective after someone is interested. For example, if I've put in the ad that we need someone who's proficient in Microsoft Word. Everyone knows that they're proficient in Microsoft Word. Everybody has a very high opinion of themselves. That's something that we should screen for on the back end of the process. A lot of times also because physical therapists have so many options for their career, we wouldn't want to try and scare that person off by putting in there, "We need the hardest working physical therapists to come and join our team." You can screen for some of those characteristics after you have someone who's interested.
What wording would you recommend? Should we maybe take a different perspective and consider what our ideal candidate would want to see or hear? Are there some things that you recommend to the owners in how they write an ad?
Physical therapists are for the most part very detail oriented. They're looking at researching jobs. They want to learn the details about the position. Sharing with them as much information as we can about the actual logistics of the role is important. I would focus my time on that rather than trying to sell someone that your clinic is a great place to work. Within the ad, I would try and focus on what are the actual logistics. I spoke with a clinic owner. She was looking at a certain work schedule that they needed someone for. Within the advertisement, I recommended that they include the actual work schedule, what time would the person start? What time would they finish? Do you need someone to work weekends? What are the actual logistics of the position? Where's the position located at? If there are multiple clinics, how would the PT spend their time between the clinics? What's the percentage? What are the addresses of the locations? Instead of like a job advertisement, it's more of a description of what the position includes and what's unique about it.
You're almost putting in the job description on the ad. I talked to Jamey about how we can write our ads nowadays because everyone is going to say they provide quality care and the patients and all that stuff in a fluffy ad that they might cut and paste. Nowadays, they probably learn a lot from your company already if they're interested in going online. They're going to check your website, which you guys have done. They're going to see if you put any recent blog posts. They'll get a clue as to if you're doing team activities or if you're working with the community and that stuff. I'd assume that they're doing some of this homework already. When it comes to the ad, maybe it is more of listing some of the details related to the position at the company.
For PTs, they're looking at what's the work schedule. They don't need to necessarily be sold. There's a lot of skilled nursing ads. It seems like every single job advertisement for a skilled nursing facility, it describes that facility as state of the art. Every single skilled nursing facility I've ever read a job advertisement for they're all state of the art. Why is that the case? What are the technologies used? What's unique about that? One thing that I've seen as well as within the advertisement, we don't want to list the essential functions of the position within that ad. Physical therapists already know basically what they're going to be doing. We don't have to list things like must be able to lift 50 pounds, must work with PTAs, all the legal description of what the job would include for the most part. You can skip over that as well.
Have you seen candidates looking for certain things that they didn't look forward ten years ago? Maybe for some of my older owners who have been looking for PTs for years, they had an ad that worked well for them, but maybe it's not working so well now. I'm wondering if there are some trends that you see in the PT candidates themselves that might be able to hook them.
There are a lot of student loans out there. If a clinic is able to offer some student loan repayment package, that's important. For a lot of our clients, a buzzword that I've heard in the last six to nine months is about passion projects. If you're a clinic owner and you would support your therapists to pursue passion projects based on their specialization. Within that, we're basically talking about allowing the PTs that you're hiring to build their own specialty within your clinic. That's attractive for folks because then it gives them the opportunity to have the feeling like they can control some of the caseloads. There might be a general outpatient ortho population at the clinic. If a PT has an interest in running or women's health or whatever it might be, they might be able to build a caseload within that niche as well.
Do you recognize that continuing education is important to them or the schedules like you talk about knowing what your hours will be, and some of the team cultures? Is any of that necessarily coming up as important to these people?The majority of PTs are passively open to considering something but are not actively looking. Click To Tweet
Continuing education is definitely important. The team culture, a lot of times the candidate will view that on the company website or during the interview process. They'll get a better feel for the team culture through there. A lot of times the clinic might have descriptions about what the team culture is like. For the most part, PTs would rather see the factual information about the position. One way to include that might be to say that as a benefit to joining our team. The job advertisement might say something like, "At Weidner Physical Therapy we have a close-knit team. This position includes a team lunch every Wednesday that we have." You're providing that detail. You're like making a statement, but then you're providing what that actually means. If it's continuing education, “We value continuing education as a result, every year our physical therapists receive X number of dollars to pursue their continued education.”
You're making a statement, but then you're backing it up with facts which would be appreciated. With the work schedule, there's a balancing act there because everyone prefers a flexible work schedule. If I have to take my daughter to dance class at 4:30 on a Tuesday night, is that going to be possible or do I have to see patients at that time? Being clear within the ad around what the work schedule is if there are set hours that you definitely need someone for, but if it's flexible then I would list that it's flexible and try to keep it like that. You can list within the ad what the hours are that would be needed or some clinics might list the salary as well. I personally wouldn't recommend that necessarily.
The best candidates are not going to be concerned with salary. That's not going to be the primary driver for them. Most smaller clinics are not going to be able to compete budget-wise with a larger organization in terms of salary. From a competitive advantage, the ad would be better if it didn't get into the salary. The other angle on the advertisement would be to look at what's unique about this position, what's unique about your practice, and how can we play that into the pain points that a PT might be experiencing somewhere else? For example, one avenue might be, "We are a small family-owned private practice. We value our employees. We consider them to be part of our family." Someone coming from a large hospital system, for example, they might appreciate that because their current position doesn't provide that. If you think about like what are the possible pain points, why would someone leave their current position, you can maybe write in your job advertisement to play into that.
We talked a little bit about active versus passive job seekers. What are your thoughts? Do you recommend either trying to recruit or creating an ad that is specific to one versus the other?
The majority of physical therapists are relatively happy in their current position. They're not actively looking. They probably don't have a résumé updated. We would call those folks passive job seekers. They're open to considering a new position, but they don't necessarily need to leave their current employer. Where like an active job seeker, if you think of a new grad searching for their first position or maybe it's someone that was frustrated with their current employer for whatever reason. They've decided, "I'm going to leave. I'm going to update my résumé. I'm going to start checking websites." The majority of PTs probably 75%, 80% are passively open to considering something but they're not actively looking. When the job is posted, people say, "I've been advertising my position for six months, but the position is only online, but someone has to go out and see it. Where if you can be more proactive with your advertising and marketing approach, you can reach PTs who are out there that may consider a new position.
How do you do that?
We all want active candidates. It's easier to work with an active candidate because they've decided that they're ready to leave their current position. Those passive candidates, they tend to be higher quality because they're working. They're happy. They're performing. The best way to do that is to be more proactive in terms of your search. One strategy would be to always have a recruitment presence. Maybe you have a job advertisement that is always up on your website. If I'm looking at some point down the road, I'll go and I'll research the clinics in the area. I'll see that this clinic has mentioned that they are looking to potentially hire someone. You can have a continual presence that might help, but the other angle to take is who is our ideal candidate. How can we contact them proactively? If you're using LinkedIn or other social networking accounts, you can send messages or request to be connected with other PTs on LinkedIn. That's often a great resource because people who are career-minded are using LinkedIn. If there are PTs that are taking their career as a PT seriously, they're potentially going to be using LinkedIn. That's often a good way. I'm not saying like post your job on LinkedIn, but actually individually search and message people on the website.
I liked what you said about constantly having a presence out there. We fall into the trap of, “Someone gave me two weeks' notice. I need to find somebody. I know it's going to take at least six weeks to find that person in a good scenario because I've got to find them. They've got to give their notice. They got to come over to me unless they're a new grad.” Even then you could be waiting for them to pass the exam. Constantly having that presence out there so that you have people on the bench. We knew once we got to the point where we had two or three people on the bench that were interested in working for us and said, "Once you guys have an opening, I'm interested."
If you can get to that point, then we knew we were winning the game. One way to do that is to constantly be recruiting, be at the fairs, be at the student affairs, and always have your job ad up. We would actually do monthly group interviews for the people that aren't PTs. That was an example of how we were constantly interviewing even if we didn't have a position open. You don't get stuck in that hair on fire, stressed out mode, taking in whoever's breathing as they come in the door as the next person in your clinic.
I like your point about the career fairs and getting in at the colleges. In terms of marketing and having that active audience of PT students is great. Once a person becomes a PT, it's likely that they're going to work as a PT for their entire career. We don't see PTs often stopped working as a PT and become a plumber or some other career path. Once you're a PT, this is your life. This is your profession. When you're looking at from a student perspective, you have an opportunity to network with such a large audience of students that are going to be physical therapists for their whole career.Posting the job and hoping that people see it is oftentimes a losing strategy. Click To Tweet
You bring up a lot of good points like some organizations think that there's this mysterious cloud of physical therapists out there. We know who are the physical therapists based on the licensure data. We know exactly if we're recruiting for a physical therapy clinic in Macon, Georgia, we can do a zip code radius and we can quickly identify the individuals who are living in that area who have a physical therapist license. Even as a clinic owner, you could obtain the licensure list of physical therapists around your area as you could do direct mail. You can have your assistant call them or send them text messages or email them. There are a lot of things. They're very time-consuming. From a recruitment perspective, even if it's a great job ad, posting the job and hoping that people see it is oftentimes a losing strategy.
You can be active in a number of different ways, whether it's LinkedIn, social media, you're going to find people who are serious about their career. I’ll have a constant job ad presence. I know something that my partner, Will, did that was successful was constantly sending out monthly emails via MailChimp. Telling a little bit about the company and what we're looking for. Even if we weren't hiring, have a nice thing that said, "If you respond, I'll send you a $10 gift card," and stuff like that. Those kinds of things, be active as you're doing it. The thing that helps is if you can make it a system and not have to come up with content all the time every month. Maybe lay out a program of, “This is what I'm going to send once a month,” and create the content ahead of time. It's a little bit easier to follow the system instead of making up stuff as you go. Focus on a couple avenues, create the concept for that, and set it on a schedule and go.
Did you guys ever do any networking events? That's one thing that a clinic might try. It would be to host a physical therapist networking session at their practice for people that are maybe interested in career opportunities or maybe want to meet other physical therapists. Maybe it has a continuing education focus or maybe not.
We never did that. I like your idea about hosting continuing education courses because I've been to plenty of clinics where they were doing a continuing education course. I wanted to learn about the clinical hours there even though I wasn't looking for something. That's a natural. Doing some networking is great. We did a couple of social hours, happy hour things where we rented out of a place at a local restaurant for an hour or two, between five and seven or something like that and invited everybody on our list to come and join us. That was it. Socialize and things like that.
Those live events are great. It helps to build the culture as well and show candidates what your culture is like. Also, from a marketing perspective, it gives you an opportunity. It gives you a reason for that contact. If you're trying to recruit someone and you have a list of people that are in your targeted area. What do you say every single time you reach out? “Do you want to come work for us? Are you open to a job?” If you have the continuing education event, you can say, "We're hosting an event next month. We'd be excited if you would come to join us." It gives you a great lead-in to invite them to something.
I remember one person we recruited. We were successful in doing so. We invited her to come to one of our clinic's annual parties. Either they broke a record or it was an anniversary type of situation. We were getting together at Topgolf. We invited her to come to that. She got to meet the team members in a relaxed atmosphere. “We're cool. We can do this,” but then also talk about business. Our employees, especially ones that were good employees would come by and say what a great place to work for. That was successful on our part.
You can have anything you want to know in your advertisement about how great a culture you have and all that. If the PT actually comes and experiences that firsthand, that's the ultimate situation. One other idea with those passive candidates would be to always move as quickly as you possibly can within the hiring process. If you think about someone who's passively interested, if they're not cultivated and if that relationship isn't built in a quick manner, then that person loses interest. If you think about it, if you're going to go shopping for a car and you go to the car dealership, you're almost instantly greeted by a car salesperson once you arrive on that lot. They engage you in the process as quickly as possible.
For passive candidates, they may or may not leave their current position. They need that nurturing in order to encourage them to actually make a transition. Contacting them within 24 hours of their initial interest, trying to move quickly through the hiring process, following up with them via multiple channels like email, phone, text message. It's a mistake that often times we're busy. We have the job advertised. We have this person that says they're interested but says, “I don't have the time. It's not the top of my priority to contact them right away.” That interest is very fleeting where they're only interested in that one period in time. We need to jump on it as quickly as we can.
Strike while the iron is hot. One thing that we found is that once we started hiring some of the high-level students, we started getting a good reputation among the other students. Usually, they run in packs. The good people will hang out with other good people. The productive people, they like to stay in a group and they socialize amongst each other. They'll spread the word around. Once you can get in with a couple of them, they start telling their friends, then you can build a reputation that helps the marketing efforts altogether.
That's the way to do it.
Do you have any recommendations on where the salaries might land for PTs at different stages of their careers?
At this point, we don't have any salary data that we keep in terms from our clients or the projects that we work on, but some good resources to check out. The APTA has some nice resources broken down by geographic area and practice setting. I'm not sure exactly how they get the data, but that would be one avenue to explore. Otherwise, we typically recommend Salary.com for people to look at. One caveat, if you're looking online, like for example, Salary.com, most of their traffic comes from physical therapists or people in general. It's not a physical therapy specific site. Most of their traffic comes from individuals who are wondering, “Am I being paid fairly?” They go to Salary.com and they take the survey. Salary.com also has job advertisements as their primary way that they make money.
With that, they tend to overinflate the salary data that they're providing such that a person going to their site would then say, "It says I should make $80,000 a year and I'm only making $65,000." That candidate would go to the salary job postings and click on the job postings and everything. I'd say it’s interesting that we've noticed that salary data, when it's from a source that also makes revenue from job advertising, is sometimes a little bit awkwardly skewed in order to promote for a candidate or for a possible candidate. They're not getting paid as they should be.Whether we like it or not, physical therapists hold the power in the hiring process because they have so many options. Click To Tweet
I liked what we've covered thus far, asking people to take a look at their ads and being more actively engaged in their recruiting efforts on a regular basis, not just when they need somebody. Are there any other common pitfalls that you see amongst owners that you could share?
With the active versus passive candidates, we definitely want to do the interview process and thoroughly screen people. We have to keep in mind for physical therapists, they have a lot of different career options. The ball is in their court. Whether we like it or not, they hold the power in the process because they have so many options. That's pretty uncomfortable for a lot of private practice owners because if I'm doing the interview process, I want to be able to ask the tough interview questions. I want to be able to evaluate candidates very rigorously. I want to make sure that I'm hiring the top quality person.
We want to ask interview questions like, "Why should I hire you? Why do you want to come and join our team? What's your biggest failure? We want to ask those questions that we see on TV that make us feel good about having that control over the interview process. A better way to look at it is this a good mutual fit from both sides and trying to build that rapport, build that interest level from the candidate. After that candidate interest is built, then would we start asking some more difficult interview questions. I call it like sell first and then screen later. The first part of the interview process would be to try and sell that candidate on why this is a unique opportunity, what the clinic can offer. Only after a period of time can we start adding in those more difficult questions. It's important to hire the top quality people but we need to build that interest first.
You feel like you want to be the interviewer that's tough. It's going to stress them and make them think and that stuff. It's like you brought up this entire time that a lot of these physical therapists are passively looking. Not many of them are actively looking. If you happen to catch them at the right time, then you're pretty fortunate. The majority of times they have a passive interest. They're seeing what the market is like and are probably relatively happy where they're at already. To come in a little bit hard with your questions can easily drive them away because if that's not what you are, then you're presenting a false front. People might not want to be in a situation where they're going to be talked to like that. You need to be aware of.
One subtle difference. It's about how we ask the interview questions. If this was something that happened to us that I learned from, but I used to ask candidates, “Why do you want to leave your current position?” It seems like a reasonable thing. You're talking to a recruiter or we're talking about a job. Why do you want to leave your current position? The reason why it was a bad question was that the candidates said, "I don't necessarily want to leave my current position. I might not leave. “They made a very firm statement, "I'm exploring this. I have choices here." That's what they were trying to portray. The way to ask it a little bit differently is, “If you were going to leave your current employer, what would be your motivation to make a change? Why would you be doing that?” You're moving from the interview process. You're giving up some of your control as an interviewer to make it a more acceptable and a softer process for the job seeker.
That opens up the interview or at least opens up for the interviewee to consider what they like about their current position and what they don't like. Maybe even open up the floor to see if what they're looking for is at your clinic or your company and see if your values are aligned. Is this a good fit? That's a much bigger question to get to the heart of that. Why are you leaving your clinic or why are you leaving your current company?
To assume that the person, even though they are meeting with you for the interview, we can't assume that they're going to leave their position. They have options. They might stay. They might go somewhere else other than your practice. Having that mindset is important. With the offer process, after the candidate is screened and after the interviews are conducted, we want to keep in mind what I talked about in terms of moving quickly through the process. Ideally, my recommendation is to try and have the candidate do one day worth of interviews. If there needs to be a job shadow or other people involved in the interview process to try and schedule that to take place all in the same day rather than inviting the person to come back. I'm not talking about changing the process or deleting any steps. I'm not suggesting to be loosey-goosey with the hiring process.
What I am saying is that as a physical therapist looks for jobs, they have many different options and oftentimes the first employer to make that job offer is the employer that will eventually hire that candidate. If you can be the first job offer, especially for a student, a lot of times students have apprehension about the process. If you can extend your job offer to that student before they've got any other offers, they might cancel their other interviews and accept your position. With the offer process, it's to extend that job offer as soon as you possibly can. If you need it to be contingent upon reference checks or contingent upon whatever you need. To say, "We've enjoyed meeting with you. We'd like to go ahead and extend you an offer to come and join the team and lead right in."
Work quickly. I can see the benefit of that because I would never ask anyone to do an interview without doing a work interview or some shadow so other people can get their eyes on this person and put in their two cents as they work with them on the floor especially if there's an opportunity for peer to peer shadowing and not necessarily you, the owner or the interviewer doing the shadowing. If there's an opportunity for them to sit with them, talk with them, get to know them and see how they interact with patients and their tone levels and stuff like that. If they have a chance to do that, then that's invaluable. I would never want to skip over that. To do it rather quickly would be a benefit to you for sure.
You also have a candidate. If they are a passive job seeker, they've taken time off of work and now they're at the clinic interviewing. They don't want to take another day off to come back and interview again. If you can try and have all of your interview steps within one day lined up nice and neatly. It may involve having it lined up, but then if you meet with someone and then that in-person interview doesn't go well, you can cancel the job shadow. You don't necessarily have to have every candidate go through all the steps. To at least have that lined up in advance like, "If the interview goes well, we're going to go ahead and bring this candidate around for the job shadow portion later."
Anything else you want to share with us, Brian? I appreciate your insight so far.
Thanks so much. This has been a lot of fun. In terms of other elements, moving quickly is the one that is probably the most important because it ties in that active versus passive candidate, ties in that, but also, if you can respond to their inquiry within 24 hours, it shows them the value that you place on your employees as well. If I'm a potential candidate and I say, "I'm interested in your practice." You don't get back to me for a week, that tells me that you don't care about me necessarily as a candidate. Maybe that's how you treat your employees as well. If you respond to me quickly, if you build rapport with me during the interview process, if you follow up, treat me well and then I'm going to feel like this makes a lot of sense. Moving quickly is a little bit counterintuitive as well because we had a situation where there was a candidate who came forward in December for a position and the clinic was interviewing that candidate.
We sent over another candidate on January 2nd, but the clinic never contacted that second candidate because they liked the first candidate. The first candidate went through the interview process. They extended the job offer to her. She declined the job offer. They're going to try and contact that second candidate for the position who's been waiting to be contacted for 25 days or whatever. We're in a situation where why didn't you contact me 25 days ago? That's the other side of it is when you have a person interested, you want to continually recruit additional backup options. Even if you have a good person lined up, you would still want to pursue the other options and move as quickly as you can on the second choices because you never know when it's going to turn into your first choice.
Some people might even say if you only have one position, feel free to hire two of them and get rid of the one that you don't like after a few weeks. Maybe a little bit harsh, but I have heard that recommendation out there as well. If people wanted to get in touch with you, Brian or with Career Tree Network, how would they do that?
Our main website is CareerTreeNetwork.com. Otherwise, we created a second website for practices and organizations that are hiring physical therapists and that one is HireAPhysicalTherapist.com. That one has all the information. I'm always happy to give advice too. Thankfully, we're a small company. We have a pretty small loyal client base that keeps us busy. From a sales perspective, I don't have to sell thankfully a whole lot of our services. We have a pretty good organic client base. I'm always happy to give advice as well. If anybody wants to bounce ideas around or whatnot, this is all I think about all day so it's fun for me to talk about it.
They can contact you through the websites or are you on social media as well?
Thanks for your time. I appreciate the insight you've provided.
Thanks a lot, Nathan. It was a lot of fun.
Brian Weidner is the President of Career Tree Network, a recruitment advertising firm based in Milwaukee, Wisconsin that helps Physical Therapists connect with career opportunities.
Since 2007, Brian has helped thousands of Physical Therapists achieve their career goals within a new position.
Outside of the office, you might find Brian playing princess with his daughters, watching heist movies or eating sushi.
I have a repeat guest, Dr. Dimitrios Kostopoulos or Dimi as we like to call him. He wants to talk about the seven facts that are changing the future of physical therapy. Dimi is a successful business owner. He has a continuing education company, Hands-On Seminars, a diagnostics company and has been on a number of boards of physical therapy in the past. I'm always interested in the insight, future thinking and vision that Dimi has regarding the profession. We'll be covering a number of different topics. As you read the different facts that Dimi lets out, I want you to consider how you might need to change in the future. I don't believe that the way we're currently practicing outpatient physical therapy is sustainable with the changes that are coming. I want you to consider what you might need to do in your practice, to make simple changes in order to navigate what's happening in the industry and in healthcare in general and where we are going to position ourselves as physical therapists in that landscape. Read the facts, consider where your standing is as a physical therapy owner and what you might need to do to change. Dimi has a lot of insights. Change is coming. We need to consider what we're going to do in the face of that change.
I'm excited to bring back Dr. Dimitrios Kostopoulos from New York, Cofounder and CEO of Hands-On Diagnostic Centers and Services. Thank you again for coming back, Dimi.
Nathan, thank you for the invite. It's awesome to be here.
You reached out to me because you've had some revelations about the future of physical therapy and what's happening. I was excited to bring you on because I'm always excited about your insight. What got you to come upon these seven factors that are changing the future physical therapy?
If we consider that we are very close to the year 2020 and if we consider how physical therapy will be beyond 2020, I strongly believe that it will be very different than what it is now. It will be very different because of necessity. There are signs that show us that it will be very different. Development on the professional front as well as socioeconomic, marketplace conditions and developments dictate that we are going to have very significant changes in the physical therapy front in the years to come. It will be crucial for physical therapists, especially those in private practice who want to survive, to understand the depth and breadth of those changes and how they can survive in a new climate of physical therapy. I should say not survive, but thrive in a new climate and the future clients of physical therapy.
It's not necessarily about survival because physical therapy will always be there. Whether or not your clinic survives a lot of these changes is up to how well they adapt and take on some of the regulations that are coming our way, implement those and handle some of the hospital networks that are invading some of their space. What are some of the signs that you see coming forward?
The idea is that physical therapists, especially those in private practice, understand and perceive the polls of the professional landscape and act accordingly. It’s managing to position themselves and their companies ahead of their competition and being able to dominate the future marketplace. Many people who are dominating many practices, who are dominating the physical therapy marketplace may not be able to continue dominating that marketplace unless they evolve. The big question is, will you as a physical therapist in private practice be one of them? One of the people who will not just survive but also thrive in the future environment. You asked me about these changes. What are these facts that are changing the future of physical therapy? There are seven facts. I'm going to go over each one of them.Many practices who are dominating the PT marketplace may not be able to continue dominating that marketplace unless they evolve. Click To Tweet
Fact one is that insurance payment for physical therapy services, especially private practice physical therapy, is projected to decrease for the next several years until at least the year 2022. We have a variety of indicators to support this fact. The Physical Therapy Business Alliance did their own research. They made the projection that reimbursements for PT services are going to decrease year after year until the year 2022. In 2015, there was a study that was published in the journal of the American Physical Therapy Association. The title of this study was Utilization and Payments of Office-Based Physical Therapy and Rehabilitation Services Among Individuals with Commercial Insurance. This study identified that although most physical therapy services are being provided by physical therapists, physical therapists receive the least reimbursement for the physical therapy services they provide compared to other healthcare providers such as physicians, chiropractors and others who also provide physical therapy services.
The Centers for Medicare Services announced their merit-based incentive program. This program promises to have very significant implications in the Medicare reimbursement for physical therapy, especially for those people who private practice. Remember that based on that program, if the services are being provided by a physical therapy assistant, there will be a 15% reduction of the allowable Medicare fee because the service was provided by your PTA instead of a PT. The American Physical Therapy Association opposed to that but the truth of the matter is that is the fact. This is something that is happening. The merit-based system is a complicated system that essentially will divide the therapists into low-performing and high-performing therapists. If there is a high performer, there is a low performer. You can't have all high performance unless you compare them with an absolute value. If you compare them amongst themselves, if you have a high performer, you're going to have a low performer.
Unfortunately, we all think that we're providing the best physical therapy out there but this is going to separate the two, the high performers from the low performers. Hopefully, they're a little bit more objective about it.
Those who will be considered low performers, they’re going to shift some part of their reimbursement into those considered high performer therapists. It remains to be seen but here are the indicators putting forward the fact that we're going to have reductions in reimbursement. I'm making a general statement, reductions in physical therapy reimbursement. I'm not talking about Medicare only. The reimbursement you are receiving from any insurance carrier of what is considered reasonable and customary reimbursement is being determined by two factors: the Medicare reimbursement in your region and the workers' compensation reimbursement in your region. If you think for a moment of what is your average Medicare reimbursement rate in your region and what is your worker's compensation average reimbursement, all of the other insurance carriers are reimbursing somewhere around these two numbers. If Medicare reimbursement ends up going down, then that is going to cause other insurances to follow suit and reduce their reimbursement for physical therapy too.
They're going to follow whatever Medicare does and if those reimbursements decrease, they'll find an excuse to decrease as well. They'll use the same formulas and whatnot. It's a race to the bottom almost. How do we get to the lowest common denominator here? If there are incentive-based programs that are going to become a part of Medicare, you can imagine those same programs are going to become part of commercial insurances as well.
I'm going to dive into fact two, which is very much related to fact one. The fact two is that more and more physical therapy private practice owners ended up settling for profit margins of 12% or less. They end up working the highest number of hours ever since they started recording these statistics. You are a member of the P2P network of the Private Practice Section. The P2P network of PPS APTA did a benchmark study that looked at the profit margins for private practice physical therapists around the country. Their ranges on profitability are from 7% to 16% and that averages somewhere around 11%, 12%. The profit margin for physical therapy across the nation is about 11% to 12%. Stop for a moment and think of this. If we end up having a reduction of services, let’s say reimbursement across the board or somewhere around 10%, then what happens with a profit margin of PTs? It’s going to decline to zero.
Another organization called Sageworks, they did an earlier study and identified that across the board profit margin for PT in private practice is 10% and in a declining fashion. They defined why they are in a declining fashion. There is a very interesting thing to consider. Besides inflation that increases while your reimbursement remains the same or decreases puts a dent in your profitability, the other thing that happens is that salaries to staff physical therapists are in an increasing trend. It’s because the demand for physical therapists is very high. The supply of physical therapists from university graduates are not able to meet the demand and regulations have become tighter. Therefore, foreign trained physical therapists that were coming into the country from places like India, Philippines, Australia and South Africa have decreased substantially because of the tighter regulations in immigration. We do have a greater shortage of physical therapists to be hired. That causes an increasing trend in the salaries that a private practitioner has to pay in order to be able to hire and retain quality staff.
The graduates coming out of school are expecting higher salaries. I don't fault them simply because a lot of them are coming out of schools with $100,000 in student loans or even more. They need higher salaries to sustain the student loans that they've taken on. The demand is always going to be there for physical therapy. I know it's hard to find physical therapists that will join your team.
Nathan, I've been giving you the negative stuff. It's not all about gloom and doom. Physical therapists are very innovative people and they are looking for solutions. Not only solutions of variability but solutions to do well financially from their profession. Fact three, physical therapists from around the world call for the expansion of the scope of physical therapy practice. There was a breakthrough article published in the October issue 2018 of the Physical Therapy Journal. The title of the article is Reflections and Future Directions on Extending Physical Therapist Scope of Practice to Improve Quality of Care and Preserve Health Care Resources. This an international collaboration, 3PPS from the US and several others from UK, Australia and South Africa. In that article, these professionals are citing the various areas of expansion of the scope of physical therapy practice in other countries outside the US. For example, physical therapists in other countries not only are they able to order X-rays, MRIs, ultrasound scans, electrophysiological testing but also order blood tests. They are able to perform joint and soft tissue injections. They are able to prescribe medications. This comes in total alignment with my core belief that physical therapists have to become the primary care providers for any musculoskeletal problems that patients get. For them to have an expansive role in participating in the proper diagnosis of the patient's problem and also managing the patients, not just treating but managing the patients properly.Those therapists who will embrace the change, who will work through the change, will be able to survive and thrive. Click To Tweet
We have the foundations to do that. Increasing our scope for musculoskeletal care is necessary and we're the best providers to do so.
Our associations are creating a significant impact. I'm going to give you fact number four. The Centers for Medicare Services, CMS, with the strong involvement of the American Physical Therapy Association and the Academy of Clinical Electrophysiology and Wound Management, fully recognized the full payment of electrophysiology studies performed by physical therapists. In an unprecedented move, the federal government issued a directive to all Medicare intermediaries directing them to immediately pay a physical therapist for the global service. Meaning both the professional component and the technical component of properly-certified physical therapists for electromyography testing, nerve conduction testing and evoked potential studies. This was a huge win for the profession, especially since the CMS language was very clear and direct about this.
A huge win for expanding our scope of care and being recognized for it.
If you remember the American Institute of Ultrasound Medicine, AIUM recognized physical therapists as the approved providers to perform musculoskeletal ultrasound studies. The PTs were recognized at the same level as medical doctors in providing and getting reimbursed for a musculoskeletal ultrasound, which is huge. AIUM is the organization that many insurance carriers utilized to decide which provider they are going to pay for the musculoskeletal ultrasound.
That's another huge breakthrough for expanding our scope. The musculoskeletal ultrasound can be so easily implemented into the everyday outpatient experience that most physical therapy owners provide. It’s such an easy implementation to add to our services, to provide better care. We can see what's going on instead of using our best guesses based on special tests and see what's physiologically happening inside the joint.
I’m going to speak fact number six. This is the result of a study that Hands-On Diagnostics performed. It was a multicenter study. It included 465 patients. The study looked at the effectiveness and the implications in patient management and patient satisfaction. When appropriate patients receive the diagnostic testing, it would be the physical therapy environment by the physical therapist such as electromyography testing and musculoskeletal ultrasound. The results of the study were astonishing. 62% of the patients who received EMG and musculoskeletal ultrasound testing by their physical therapist had a change in their management which was caused by the results of the diagnostic studies. A patient who went to a physical therapy practice, the physical therapist performed a physical examination, wrote a treatment plan, but then decided to do either an EMG or an ultrasound study because something was not going right with the treatment. The patient filled out an assessment form and revealed that the patient could be a candidate for these diagnostic tests. The therapist performs these diagnostic tests and in 62% of the time, that original treatment plan had to be altered because of the results of the studies. That’s pretty amazing.
Going into a study like that you'd think, “Maybe some diagnostic testing would change 25%, 33% of the plans of care that were laid out by these experienced.” These aren't brand new physical therapists but experienced physical therapists that are doing all the “appropriate test” measures and whatnot. To say that 62%, almost two-thirds of the plans of care were changing based on diagnostic tests says a lot.
What is ironic about this is there’s a different study that was done by a group of urologists was published at Muscle & Nerve Journal. It was entitled, The Usefulness of Electrodiagnostic Studies in the Diagnosis and Management of Neuromuscular Disorders. This study found that electrodiagnostic studies lead to a change in diagnosis in more than half the patients and lead to a change in management plan in more than 60% of the patients. It's interesting that when that study was done in a medical environment, they realize that electrodiagnostic studies end up causing in 60% of the cases a change in patient management. When we did a similar study in a physical therapy environment, we found that 62% of the cases, the patient management changed. It's very comparable.
It’s almost the exact same results. It goes to show that we could benefit from some diagnostics to assist us.
Another thing is how patients understand their problem when they see a physical therapist. You're going to get greater compliance when a patient understands their problem and then becomes willing to participate in the solution. In our study, we found that 90% of the patients strongly agreed that they were better able to understand their problem. Able to manage their problem because of the answers they got through the diagnostic testing performed in the physical therapy clinic.Think out of the box. What you learned at the university when you graduated was amazing but not necessarily enough for the future. Click To Tweet
Diagnostic testing makes everything more objective. When you get an ultrasound, “Here's the picture of the bone spur in your shoulder. Here is where the tear is in your rotator cuff or with the electrodiagnostics. Here is your level of nerve damage is that L-four on the left side. These are the findings that show that.” There's no guessing anymore. Having some diagnostics on our side makes not only our plans of care improved, our treatment efficacy improved, but also improves our standing with patients and with the medical community that we're doing and treating the right things.
We put all these things together that I discussed thus far. The decrease of insurance reimbursement for physical therapists in private practice, the very low 10% to 12% profit margins for physical therapist in private practice. The fact that physical therapists around the globe are talking about expanding the role of physical therapy in including a lot of these diagnostics. The fact that our associations are creating conditions. Circumstances with the involvement of the federal government for the recognition of physical therapists. Performing both musculoskeletal ultrasound as well as electrodiagnostic studies. That creates an environment to have a different type of physical therapists tomorrow. You're going to have physical therapists who will embrace these changes, who will study, change, evolve, get involved, and change their whole operation in their practices.
Incorporating diagnostics and you're going have some physical therapist school will deny the change. In my opinion, those therapists who will embrace the change that will work through the change, they'll be able to survive and thrive, the same way that many physical therapists have done across the country. I'm going to plug Hands-On Diagnostics, it’s imperative because it's data. We have data that physical therapists who are performing diagnostics are able to retrieve reimbursements from insurance five to ten times greater than the single physical therapy visit. That can create a huge impact on somebody’s facility. Not only offering an amazing service for their patients but also getting paid well for that service.
To speak to what you're talking about in regards to the future of physical therapist, you bring a realization that physical therapy as it is constituted might not exist in the next ten years. There will have to be some evolution to what we're doing and what we're providing. It isn't to say that our practices will go away. That's not the case whatsoever. We need to expand our scope. We need to be doing more to create a bigger footprint in the medical community. We do that by including diagnostics into the services and becoming the gatekeeper like we want to be. That cannot only improve physical therapy that can improve the healthcare system in general. We know that if we are the beginning point for any musculoskeletal condition, then the cost of that episode of care is going to decrease substantially.
The thing is we have developed the systems and technologies to help somebody implement this in their practice very easily. When you came into HODS, it was still in its infancy stages. Many changes have taken place and HODS has become the only organization worldwide to offer both a residency in clinical electrophysiology and a fellowship in musculoskeletal ultrasound sonography. Helping therapists to achieve board certifications at the record time.
These changes are huge. There will be a huge impact. What would you say to a young physical therapist who's starting? Maybe being into his clinic as an owner for less than a year, what would you say to someone new regarding some of these things that we've talked about?
Think out of the box. What you learned at the university when you graduated was amazing, awesome, fantastic but not necessarily enough for the physical therapy of the future. Physical therapy beyond 2020 is different than physical therapy before 2020. I would say look around, think of what the changes to come are. There are other changes that I did not mention. The areas of telemedicine, for example, are very important areas that will evolve both as clinical models as well as educational models. You have to look around at various areas and really jump ahead of the competition. When you have the marketplace, you have competitors. In the physical therapy area, there are competitors. The way to get ahead of the competition is to identify specific niches that the people need, want, buy and offer them massively. You can become the leader in what you are offering in your area.
Set yourself apart by looking ahead. Someone who has a new practice like that can be nimbler. They can pivot and move into other niches, specific types of care in other parts of the industry that maybe a practice with four or five physical therapists can't do. Thanks for your time, Dimi. I'm excited to see what the future holds. I know you'll be at the forefront of it with all of your hard work.
Thank you for the invite, Nathan. Anytime, you and your audience can reach upon me.
How can they reach you?
It’s very easy, I’ll even give my cell phone. I keep open communication lines with everybody. Anybody can reach me at 917-538-2242 or go to www.DiagnosticsForPT.com. If you get to go to DiagnosticsForPT.com, enroll to receive for free the Diagnostics for PT Magazine, which is a quarterly magazine that can be mailed out to you free of charge, if you would like to find out about the latest things in the physical therapy industry.
It's got a lot of great information in there as well. Thanks again, Dimi. I invite anyone who is interested in looking forward to what the future might hold for physical therapy. Reach out to Dimi and give him a call.
Nathan, thank you for what you're doing for the profession.
Thank you, Dimi.
Dr. Kostopoulos is a Board Certified Clinical Electrophysiology Specialist with over 29 years of clinical experience and over 20 years experience in electrophysiology testing. He is one of very few Electrophysiology Specialists who have achieved a Doctorate of Science (DSc) in Clinical Electrophysiology Testing.
He is a Clinical Affiliate Assistant Professor. at Charles E. Schmidt College of Medicine at Florida Atlantic University, past member of SACE (Specialization Academy of Content Experts) for the electrophysiology board exam of ABPTS and serves as an elected member of the Nominating Committee of the Academy of Clinical Electrophysiology (ACEWM) of the APTA. He is also an Adjunct Faculty of Springfield College teaching the Clinical Electrophysiology module.
A world renowned, leading expert and best-selling author in Myofascial Pain and co-founder of the Hands-On Companies (Est. 1992 in New York). Dr. Kostopoulos has extensive training and teaching experience in different areas of manual therapy with an emphasis in Trigger Point, MyoFascial, NeuroFascial Therapy and Manipulation.
He earned his Doctorate (PhD) and Master’s degrees at New York University and his second Doctorate of Science (DSc) degree at Rocky Mountain University (Clinical Electrophysiology). Dr. Kostopoulos has obtained his MD degree as a medical graduate from UHSA School of Medicine.
He has numerous publications; he is an Associate Editor for the Journal of Bodywork and Movement Therapies published by Elsevier and has taught thousands of students worldwide through Hands-On Seminars.
I'm excited to have the opportunity to interview Dr. Heidi Jannenga of WebPT. If you don't know Heidi, she is the Co-founder and President of WebPT, the country's leading rehab therapy EMR platform for enhancing patient care and fueling business growth. Since the company's launched in 2008, she has guided WebPT through exponential growth. It's the fastest growing physical therapy software in the country, employing nearly 500 people and serving more than 75,000 therapy professionals at more than 12,000 clinics. WebPT is also ranked five consecutive times on the prestigious Inc. 5000 list and twice on the Inc. 500. She has been recognized as one of Health Data Management’s Most Powerful Women in healthcare IT, an entrepreneur of the year finalist by Ernst & Young, and most admired leader and tech titan by the Phoenix Business Journal among other accolades.
Prior to co-founding WebPT, Heidi practiced as a physical therapist for more than fifteen years. She regularly speaks as a subject matter expert at local and regional technology, entrepreneurship and leadership events as well at national PT industry conferences. She serves on a number of Boards and organizations including the Arizona Science Center, Support My Club, the Physical Therapy Political Action Committee, the Institute of Private Practice Physical Therapy, Conscious Capitalism, AZ Chapter, and the Arizona Community Foundation. She also dedicates time to mentorship within WebPT through her women's empowerment group, PropelHer and in the broader community through her work with physical therapy students and local entrepreneurs.
WebPT came out with their state of rehab therapy based on a survey of over 7,000 rehab professional respondents. Heidi and I are going to talk about four things that came to the forefront from their surveys. In this episode specifically, we're going to focus on one striking aspect that has to do with physical therapy ownership. That is the fact that a number of owners lack a marketing strategy. They're unaware of what they're spending on marketing and they most of the time fail to have a growth strategy in place. We are going to talk about some of the data and statistics that came from that and also look at some of the past, current and future trends for new patient acquisition. I hope you get a lot from this episode, but you can refer to the WebPT report it's on their website. Go ahead and check it out.
My guest is Heidi Jannenga, the Founder and Owner of WebPT, a leader in our industry. Thanks for coming on, Heidi.
Thanks so much for having me, Nathan. It’s an honor to be one of your guests.
I know everyone throughout the industry knows about WebPT. Do you mind going into a little bit of your backstory and sharing with the audience where you came from as a PT or even prior to that? What got you to where you are ten years into your ownership of WebPT?
My interest in physical therapy started when I was in college. I was a high school athlete. I went on to play basketball at UC Davis in Northern California and injured my knee during my junior year. I was pre-med going into college. I had a knee injury, the MRI was inconclusive, but they saw some things going on with my ACL. They said, "We're not sure. We don't want to go in for surgery. We're going to send you to physical therapy." I've been in the athletic training room as most athletes know very well but hadn't had much experience at all with physical therapy. I was sent to an amazing therapist whom within about ten weeks had me up and running and back playing again with a brace.
It intrigued me to learn more. I did a few volunteer internships and I ended up going on to PT school after I graduated from UC Davis. I went to the Institute of Physical Therapy, which I was in the inaugural class with Stanley Paris and Catherine Patla for their Master's program. They had done a lot of postgraduate work, but this is their first program. That was a unique experience. I had lots of training from two amazing gurus. Then I went on to practice sports medicine in private practice. I practiced for about fifteen years and worked my way up over time to clinics directors. In 2006, I was a clinic director over a few clinics here in Arizona. One of our biggest expenses was transcription and dictation.PT owners lack focus on marketing and growth strategy. Click To Tweet
A lot of our referring physicians had transitioned into using some digital documentation or electronic medical records. I thought there had to be something out there for therapists. I went out, found some very clunky server-based platforms that were super expensive. Even at a clinic my size which we had about 40 employees, I still didn't think it was an appropriate capital expense. I partnered up with a software engineer and we put our heads together. We built something that was originally just supposed to be for my practices. We’ve got something up and running and got very positive feedback from my therapist. It took about nine months to build. Then within the next six months after we got our clinics up and running, some of my colleagues said, "What are you doing over there? We want to try it."
Within another six months, we had about ten clinics up and running, all giving us positive feedback. We continued to iterate on the process. In the middle of 2007, we decided to do a little bit of market research and found that 80% of therapists were still documenting on pen and paper. The light bulb went on and we decided to launch the company in February of 2008. We launched the Combined Sections Meeting in Nashville in 2008. We had no customers outside of those that we had in Arizona who were using our platform and one employee. We are celebrating our tenth-year anniversary, which is amazing. It's like the blink of an eye, it's gone by that fast.
That conference with one employee, I'm sure that was just like a hockey stick that went straight up.
It's been an incredible ride. We now have 500 employees. We’re not just located here in Arizona, but in eight other states and serving 12,000 practices. I stopped practicing in 2011 after my daughter was born, and that was a hard transition year of going away from your identity as a person, your career. Obviously, I still have so much pride in being a physical therapist. I maintain my license, you never know one day I might be back treating patients again.
Making that transition from patient care and even as a clinical director to owning a business had to be a huge transition. A lot of support, coaching, consulting that came into play and helped a lot to mature.
I always have used mentors along my path in my career, in general, to learn about best practices, to learn about speed bumps that I could prompt potentially avoid. What was interesting though, which finally made my transition a little bit easier, was to fully grasp and understand my clinic director leadership knowledge of running a business. We basically ran our clinics even though the ownership wasn’t my company or my clinics, but running it like you were an owner. The people leadership and the culture of our clinics were those skills and that skill set was immediately transferable into building a software business even though it was completely two very different industries. The quicker I recognized that allowed us to ramp up and allowed me to feel more confident in completely switching industries at that point in my life.
We're going to go into your report that you put out here in the last couple of months based on your surveys. What are some of the things that WebPT is focusing on and looking to in the future?
Over the last three to five years, we've expanded way beyond just being an electronic medical record. We’re much more of a portfolio platform company for rehab therapy. We've never wavered in terms of our focus on rehab therapists, which includes PT, OT and speech. Our core is the EMR but on top of that, we've added so many more digital tools for clinics to run their businesses. This includes patient retention management, which is a way for therapists to continue communicating and retaining patients within the community that they've built and worked so hard to get into their practices.
We have multiple ways of billing on behalf of your own practice, whether you like to bill on your own. We have a platform called Therabill for smaller practices that you're able to do. We made a huge acquisition with BMS with John Wallace's company who is now part of the WebPT portfolio, which we offer a revenue cycle management as well as what we call RevEquip. This is a hybrid model where you can still do some of your billing and maintain some control. We also help you to make sure those claims are getting to insurance companies in the cleanest manner that they can be. We offer a whole lot of cool functionality beyond just the electronic medical record.
One of the most important things that we always try to utilize in our clinics and recommend the same is especially as owners come around if they haven't already and they need to be, is to recognize their KPIs and having an all integrated software like yours. They need to be able to easily obtain those reports and know exactly what the health of their clinic is like. You have developed that out.
That has been our main goal over all of these years. We were the first web-based application to enter the market which is significant because all of the data is held by us as a software company versus server-based companies. The data lives in your practice. With all of that data, we have the ability and what we are doing with the analytics program is offering benchmarks. We have such a density of clinics all across the US and the platform of information and data. We're able to show a significant KPIs of what those benchmarks could look like across the country. Our ultimate goal of triangulating outcomes with clinical data along with payment data.WebPT can support owners with their internal marketing via their Patient Retention Management tool Click To Tweet
Understanding how those three worked together to hopefully influence more and more, which is our main mission. Our mission in general is to empower therapists to achieve greatness. Part of the greatness we feel is trying to conquer this 90% problem. This is the 90% of people out there who don't know that physical therapy exists. They're not getting into our car clinics across the country because either they're not getting referred in with the appropriate diagnoses that we could help them with or they just don't know who to turn to. They don't know that we as therapists have to deliver the value and help them with their ailments. We're all fighting over this 10% of people and wondering why we can't get more patients in the door, which is a great segue into why we created the industry report.
When I saw it come out, I thought, "This is such valuable information." I hope all the physical therapists are taking the time to just look over it. You have a PowerPoint presentation that breaks it down easily into graphs and simple statistics. It's a survey that includes over 70,000 respondents across the nation, across the rehab spectrum and this is your second one, right?
Yes, it's our second annual. Part of who we are is what PT is from the beginning. We wanted to build a community. It's partly why we call our customers members because we’ve built this community around WebPT. A big portion of that is around education. We offer lots of free webinars. We did an amazing one around billing, the nuances of billing. We make sure that we have the most knowledge available, pushed outward to everyone, not just people using our software. That's a huge gap that people are nose to the grindstone treating patients all the time, but there's a world around them that's changing with compliance and regulatory change, billing and knowledge and technology for that matter. To help enable them and automate some of the processes that they have been struggling with and just don't know how to use.
That's been a big part of who we are as an organization as WebPT. The data play is also big. We took on doing this survey because when we went out and asked a lot of questions to as many resources as we could think of, we couldn't get answers. In the WebPT way we decided, we're just going to go find out the answers ourselves. We put out this amazing survey and got about 5,000 respondents. We took the feedback from those who downloaded the report and had more questions. We added to the question poll. We got over 7,000 respondents and I've put together this amazing report. You can download the report if you go to WebPT.com, State of Rehab Therapy report. I think it's more than 70 pages long. Don't be intimidated by that because we break everything down into small, digestible bites of such great information about the industry. I'm so glad that we're able to do it.
It was easy to read. You say 70 pages and I don't want people to get scared off by that. If you take the time, you can skim through it. You do a good job of highlighting the important information. I recommend everyone going through it and reading it to see where we're at on this in the state of the industry. It’s valuable information and what you’re talking about also in regards to benchmarks and how people are doing across the country. It's extremely valuable for physical therapists to know what's going on outside of themselves and/or outside of their community, outside of the state, just to look outside the bubble a little bit. As you put together this report, I know that a few things stuck out to you. I'll let you talk to us a little bit about those four items that you noticed after reviewing the survey results.
We can go into each one a little bit more in depth. There were pretty much four takeaways that we wanted to make sure everybody got from this report this year. The first one is the lack of focus on marketing. With our transition, I shouldn't even say transition because we've had direct access in most states for quite a long period of time. This transition into understanding is not just about marketing to physicians, it's also about marketing to the consumer. The consumer who is potentially the patient. This is where that whole 90% comes in that we've never necessarily understood how to attack. This change in mindset requires marketing and a knowledge of marketing.
We were a little bit astounded to be honest, even from the large enterprise groups who responded to our survey. Most people don't know what they're spending on marketing and they don't know necessarily what the ROI is on what they are spending. The second one and we've written a couple blogs that had a lot of interest and a lot of feedback on is around this mounting student debt. We're not alone in terms of our students who are going through PT school. We've made this transition from masters to DPT. We have people seen value from that. Obviously, increased in price has gone up for going through to get a DPT, but that hasn't necessarily shown up in our paychecks when it comes to first jobs and what we're able to pay therapists.
Alongside that is also something as a woman and a female therapist and as a feminist, the mounting gender gaps that are better in healthcare than in most other industries. It's not bad in PT, but it still remains pretty significantly. We’re addressing that and we had some good feedback around that. The last one is high patient dropout rates. When we consider that we're only getting 10% of the overall population that could use us, then you have patients that aren't even finishing their plans of care, the number of people that we’re touching and have the ability to get great outcomes with significantly diminishes if you're not paying attention to those dropout rates.
We've always talked about retention or rival rates, cancellations and no-shows. We definitely pay attention to that. What we're talking about is the whole episode of care. If you thought that they should be there for ten visits, but they drop out at three, the outcome of that is not positive. It could be. There are lots of scenarios that you could say, "They got better in three visits. That's awesome. You're a great therapist." They walk away saying positive things, but it's a lost opportunity to leave a longer impression on what physical therapists do and how they can continue to help you and keep them in your community.Owners need to recognize what their therapists are saying. Click To Tweet
You talked about having a lack of focus on marketing and growth amongst the ownership. It's interesting that it might have been a month or two before you released your report, but the APTA also put out and showed the physician referrals are at an all-time low. From 2003 to 2014, referrals from physicians had dropped over 50%. If that's not just a red flag that the days of focusing on physician referral and putting your money and shoving your money into that space isn't going to get you very far, it's just not happening anymore.
It's no coincidence that the opioid epidemic has also occurred during that time.
I didn't make that connection.
It's an interesting path of one going up as one comes down. APTA was specifically focusing on PT referrals. That can be positive if you think about it the number of patients coming into practices hasn't significantly changed. There are more people who need us, physical therapists, as PT continues to grow in terms of the Baby Boomers. There's more opportunity for us to see patients. Hopefully, the direct access has improved. I know we've done a bit of a push. A lot of people are now much more available to take patients in without referrals from physicians. Insurance companies have jumped on board, the Medicare no longer requires it on their first visit. There are a lot of things that have come into play to allow that statistic not to be super negative. I'll just harp on the 90%, we're still not getting to the people that truly do need us. They're seeking other avenues or physicians are giving out medication instead of getting to the root cause of what's causing musculoskeletal pain, for example.
What we're seeing at least in our clinics is that physicians are telling our marketers nowadays we don't guide where the patient's going to go. We give them a prescription. We know you are out there all over the place. Just see who's in the network and decide for yourself. More and more physicians are doing that. I see that in Arizona and our clinics there, but also up here in Alaska as we're talking to some of the physicians. The people need to understand that trend. If we can take it positively, it's our opportunity. In one way you could say we're getting forced in this direction, but let's go after the 90%. There's a big pool of patients out there and you know as well as I do that a lot of times PT owners can get very competitive in their spaces geographically. When we recognize that, we're only fighting over the 10%, there's 90% more business out there. We need to jump into a bigger pool and make a difference.
That will do two things. Number one, it can increase our access to the number of patients. Number two, it needs to extend the awareness of physical therapy. I'm sure you saw it when you treated and I saw it as well, but patients asking me, "Do you guys treat low back pain?" "Yes, all the time." Getting that awareness out is imperative upon us and to focus and put more effort. Recognizing where our money's going, what the ROI could be and should be for marketing those people. Getting the word out that we are the rehab experts. The doctors have some good ideas, but we know how to overcome your musculoskeletal pain.
It's working together with the physicians. You never want to throw anybody under the bus. On our billing webinar, there was a question about the fact that they're starting to get primary diagnoses from physician referrals, opioid addiction and long-term drug issues. They were like, "Is that okay? Can we actually treat these patients?" They have secondary issues, a muscle weakness and abnormalities and strength problems. I was like, "Are you kidding me? Everyone on this webinar should be cheering as loud as you possibly can seize this moment." There are so many people who are having to change their medication and take them off these opioids and they're still in pain.
Having physical therapists be that alternative to these pain medications is absolutely an opportunity that we need to be seizing. That may be their primary diagnosis that we can't treat them for that, but here are all of the other problems in pain which got them to that place, which we can treat. That's the one that we should be able to be doing. When it comes back to marketing, which is exactly what you were talking about, people and even physicians are no longer necessarily referring to some specific person. I still think that relationship with physicians is very important.
It's super important they're generalizing because of the way that people are searching. There are lots of studies out there that show that patients will go online before they do anything and decide where to go regardless of what the physician said because they're looking at online reviews. They're looking at your website, they're are checking out anything that anyone's ever said about you if they referred to you specifically. They want to know about the clinic. That's an impression before they even walk in your door if you don't have a website that truly reflects what you do in your practice, the diagnoses that you treat, what it looks like, online reviews, you're missing out potentially on people that are going to be looking for that. I think that 72% of patients use online reviews as the first step in finding a new healthcare provider.
You better have your website dolled up. It's got to look good.
At least you need to be present on Google Maps, on a Google Search. You have to be out to have an online presence these days. It's a no-brainer.It’s imperative that patient experience is seamless in every business. Click To Tweet
You've got to come to understand some digital marketing. If you're not tech savvy, find someone who is. There are companies out there that will help you. I know you did a Webinar with Neil Trickett over Practice Promotions. I've interviewed him as well. I will interview more in the future like David Straight from E-rehab. These people will help you. They work specifically with PTs to get your digital marketing presence out there because to solely referring physicians, you’re behind. There are times you’ve got to pull your head out of the sand and recognize that people are looking at your digital presence more than your physical presence than anything else. Even though they get the word of mouth, what's the first thing they're going to do? "Let's check out the website. “
Once they're there, you’ve got to show value and customers service. It has to be impeccable from the time they walk into your door with your front office, which we call our first impression officers to when they leave and the how the billing goes. All of those nuances. When I was practicing, we could get great outcomes for our patients. They loved as clinically but if we messed up on their bill, we were dead to them. It's hard to part that. It was difficult sometimes if we had those building experiences, but it's about the patient’s experience from start to finish. Every piece of that becomes more and more important because people are looking for value. Especially with the higher copay amounts that suppose these days you've got to show them value. They want to know the outcome. They want time with you. They want to understand the why of what you're doing. The digital tools that are available out there, which the WebPT portfolio has a lot of them, but regardless of what tools you're using, it's imperative that patient experience is seamless but also shows value. That's part of marketing.
I like that you talked about showing value to the patients that are already with you because that could be huge. Getting a return patient is huge. It's a part of marketing that I call it internal marketing. I know other people call it the same thing or something else. That internal marketing part of it is extremely valuable because these people are going to be spreading the word of mouth. They're going to be providing you referrals via word of mouth. Are there some things that are within WebPT that help the clinic owners and the practitioners improve their internal marketing?
Yes. We acquired Strive Labs, which we call WebPT Reach, which is a patient retention management platform. In which you can put out newsletters, texts messages, keeping contact with communication through a mobile app with a patient's digital home exercise programs in which you can provide feedback through. It's this patient connection that we have emphasized over the last couple of years. It is so important and it's a differentiator because they want you. They may not be able to come in to see you as for as many hands-on visits as previously we were able to do. Evolving our practice in how we think about things has to happen. We're providing those tools to do that. We have the patient call reminders to make sure that you are minimizing those cancellations and no-shows and making it easy and seamless from the beginning of a digital intake to capture a lot of information from the patient, so you can get some of your preliminary insurance verifications done. When they come in it's like, "We're happy to see you. Here's what we've already done for you." That patient experience is just stellar from the beginning.
That's cool that you've incorporated all of that into the EMR, so someone doesn't have to click out of your website or out of the app to find what they need. They can only do within there and see all the notes pertaining to that patient and send individual emails or mass emails if that's what you need to do like you said with the newsletters.
The internal marketing piece, I always think about it from an educational perspective. Having our outcomes platform built-in and integrated to where you can share that information with the patient in terms of how they're progressing along their path. What are some of the things you’re specifically going to work on and getting that feedback from the patient and what they still can't do? Collaboratively working with your patient on goals. It makes them part of the process. That engagement helps to make sure they are going to be completing their entire plan of care per your expertise in what you've given to them.
I know it’s abrupt and I’m sorry to interrupt the interview with Heidi. We talked about a ton of stuff in our interview. I broke it up into two parts. The next few topics we’ll be going into, we’ll be able to delve into quite a bit. I’m breaking it up into two episodes, so stay with me. In the meantime, Heidi made it known to me during the course of the interview that she is offering a special promotion for the WebPT Ascend 2018 Conference coming up this September 27th through 29th in Phoenix for my Physical Therapy Owner Club audience. She has setup a special promotional code so that when you register, in the promo code box, type in PTOWNERSCLUB and you’ll get a special discount for your registration for Ascend 2018. A select conference for PT business owners and their staff. Make sure you recognize that, it’s not just for the owners but also for your admin staff and your billing staff. Stay tuned and join me for the second episode of my interview with Heidi Jannenga. Be sure to register for her conference. Also, please subscribe to the podcast and leave a review. It’s huge for podcasts to have a number of subscriptions or subscribers and reviews on the podcast. It helps in growth and attraction to other podcast listeners. As a favor, please do that as well. Stay tuned.