PTO 98 | Social Media Marketing

 

Social media marketing and advertising may be new for many physical therapists, but amidst the COVID-19 crisis, it is a marketing avenue that physical therapy owners need to consider. Joining Nathan Shields today is Edric Zheng of Medical Patient Referrals. Edric provides some of the basics about the why, how, and what is best to do when it comes to marketing on Facebook. Stick to the end for useful strategies in making irresistible offers, generating good content, broadening your audience, building a database and many more.

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Facebook Marketing For The Physical Therapist With Edric Zheng Of Medical Patient Referrals

My guest is Edric Zheng out of New York. He is with Medical Patient Referrals and he is an expert on social media marketing. I thought it'd be appropriate to bring him on, as owners have the time to consider their digital presence, the marketing that they do digitally, especially as we've been forced in that direction with the Coronavirus pandemic. First of all, Edric, thanks for coming on.

Marketing is only as powerful as your sales process. Click To Tweet

Thank you, Nathan, for having me. I appreciate it.

Tell us a little bit about you, Edric and what you do for physical therapy owners, but also a little bit about your backstory and what got you to the point where you are now.

What I do is I set up a direct access patient generation system using Facebook ads to help them acquire new patients with social media and to take advantage of all this traffic they have available to them. My background is I've spent a few years in digital marketing, learning copywriting, running ads, and creating profitable campaigns. Also, spending a ton of my own money trying to figure things out for my eCommerce products as an affiliate in my previous life for other health companies and nutraceutical products. That's how I got good at Facebook ads. I’m using those skills and taking it to help physical therapy owners with their patient acquisition systems and processes.

You've been spending a lot of time trying this, trying that, and refining content when it comes to Facebook ads. Why specifically do you focus on Facebook ads? Why are Facebook ads beneficial for physical therapists?

The reason why I focus on Facebook ads in the past was there’s so much opportunity there. Almost everyone that I know is on Facebook. Probably the same for yourself as well.

PTO 98 | Social Media Marketing
Social Media Marketing: Facebook has around 2 billion users worldwide, and the biggest growing demographic on the platform are people over the age of 45.

 

It's probably two billion Facebook users or something like that on my side of the country?

People spend 30 minutes to two hours a day every single day on social media and the biggest growing demographics on Facebook are older people, over the age of 45. People are getting on so they could spend more time connecting with their family and look at photos of their children and things like that.

How did you utilize Facebook to drive direct access and patient generation?

What do for a client specifically or for my own company?

We want to be more PT specific. What do you do specifically for physical therapists to help them get direct access and patient generation? To some extent, we already have some direct access capabilities with physical therapy.

It all started with creating an irresistible offer for someone to want to come in and start a conversation with you. For example, it could start with maybe like a free consultation offer if you want to be super basic or free discovery visit, a second type of offer. It could be a workshop if you haven't experienced hosting those types of things. It could be something super unique that you do and that no one else has ever seen before, like a free laser therapy session or something like that. It all started with coming up with an irresistible offer and then putting that on Facebook.

Physical therapy only needs to be specific or at least have a niche in which they can offer or somehow be able to share some of their knowledge base in order to gain that traffic and that interest.

When it comes to paid advertising, all you need is an ad text and an offer and you can start promoting that to almost whoever you want. You can start showing your offers and what you have to offer, the value that you can provide. You can start showing that to thousands of people if you have a couple of bucks to spend on Facebook.

With the number of people on social media, especially Facebook, during the COVID-19 crisis, it's an opportunity to gain a bigger audience. Click To Tweet

When I consider Facebook and talking to some of the marketing specialists, you want to get that patient in front of that patient as much as possible so that they click and buy or sign up for whatever offer you're providing. There's added value in simply gaining an email address and that’s building your list so you can send them future offers.

Getting an email address means that this person is interested in what you have to offer. It means that this person has back pain, knee pain or maybe has been involved in a motor vehicle accident or just has gotten out of surgery. They’re looking for related content. They're looking around and they're trying to find out who they can trust. If they're on your email list, that means you have a line of communication with them where you can continuously provide value, educate them, and build that trust until they're ready to come in and start a conversation with you or get the help that they need.

How does someone go about creating a successful marketing campaign on Facebook? What process do you recommend they go through?

If you wanted to, physical therapy owners can look at the different clinics in their city. Go on their Facebook pages and look at their ads that they're currently running because that's all public information that Facebook has made available to all advertisers to promote transparency. Being able to reverse engineer what's already out there and what's been running for a long time is probably the best way to start to do what's already working.

How long do you recommend someone keep a Facebook ad up before they determine if it's successful or not? Do you give it 2 or 3 days or do you give it 2 or 3 weeks before you look back and assess what the statistics are?

PTO 98 | Social Media Marketing
Social Media Marketing: When it comes to paid advertising, all you really need is an ad, a text and an offer. Then you can start promoting whatever to almost whomever you want.

 

Since we have a lot of data already on Facebook ads, a KPI that physical therapy owners should look out for is the cost per lead metric. If they're seeing their cost per lead go above $20, pause that ad and then to try again. Try a different offer, image, video, and angle. You want to try and get your cost per lead to around $10 because that's where we know that you can have a lot of success if you can get there.

You're saying $20 is the point at which you want to reconsider what you're offering and what that looks like in the design and whatnot. When you say $20 per lead, that's not necessarily a converted lead. That's just simply $20 per lead.

That $20 is just someone who's seen your ad, who's given you their name, email, phone number, and is interested in whatever you have to offer on Facebook, be it a free consultation or a $21 evaluation or something like that.

You want to keep that number then below $10, is what you're saying?

Yes, if you can keep it around $10, that is ideal because you're not going to convert every single lead. That's why you want to have a good amount of leads coming in at a solid price.

What are some of the most successful things someone can do as they're setting up this strategy? What are some of the components of having a successful Facebook strategy?

For us, it always boils down to four things. Number one is your offer. What do you have to offer to get someone to want to come in or give you their information? That's probably the most important thing. Number two is your creativity, which could be your image, a video or a testimonial that you're attaching to that Facebook ad. That's the second thing that people pay attention to. The third thing is your headline. Does it stop people from scrolling on social media? Does it get them to pay attention to what you have to say? The fourth thing is your body text. It’s whatever else you want to put into the Facebook ad and things that you want to say to keep them reading in on your Facebook ad. Whatever you write in your ad, it has to be whatever the conversation that the person is already having in their head. If you can answer that conversation and you can put that in the text format, you're going to have a lot of success.

Do you find more success with video-based advertisements versus those that are simply text?

For sure. Video allows you to build a lot more rapport and a lot more trust that you can't do with photos or with text.

How long should a video like that be? Do you have any recommendations?

If you're going after an audience that doesn't know who you are yet and people around your city, it’s maybe around 3 to 5 minutes providing value and educating people so they know that they can trust you and they can use what you have to say.

It's an obvious answer but I'm sure in the body of the text, you're wanting to refer them over to the landing page and a YouTube channel that you might have generated or other social media as well?

If you take them to a landing page, you can sell them some more, you can provide some more testimonials, and you can tell them more about your product, whatever you have to offer. It gives you another chance to sell them again and to qualify someone before they come into your funnel.

Effective advertising starts with an irresistible offer for someone to want to come in and start a conversation with you. Click To Tweet

For me, creating content is my biggest fear. I can do it and I'd do it, but for someone who isn't into developing that content, how would you guide them to make an irresistible offer that gets that client or that potential lead to reach out?

You have to put yourself in the perspective of your end client or your end customer and think about what is it that they want and what they find valuable. Put yourself in their shoes and think about whatever it is they would find useful. I would test that as an offer or a content to give away.

One of the books that I refer to is called Building a StoryBrand by Donald Miller. Interestingly, he recommends the same thing. When you're advertising to somebody, you don't want to come across as the hero in their story. If you're advertising to somebody, they want to be the hero of their own story and you want to be essentially the guide like the Obi-Wan Kenobi that takes this person who doesn't know their strengths and what they're capable of and develops them. That way, they can become the true hero. That's good advice. What you're saying is that you want to talk to them as if you are the guide, but not the hero to their story. We have to remember as physical therapists that we can't use our jargon, our vocabulary, especially the specifics. You want to get down to their level and talk about, “Do you have back pain that's keeping you up at night?” Without getting into the technicalities of it, per se. “We have the four things that you need to do to sleep better.” Something like that. By saying that, do you find that content that has a list of the 4 or 5 things or how to blank that kind of thing? Is that helpful?

Yes. Those types of content always do well. A good way to know if your video content is doing well is there's a metric you can look at on Facebook ads. It's called Cost per ThruPlay, and that's how much it cost you to get a fifteen-second video view of your ad. If that's under $0.06, that piece of content is good because that's another good metric to look at in your Facebook ad.

These are all metrics that you manage via Medical Patient Referrals but it's something that people can also look at themselves if they are admins on their page?

Exactly. These are numbers that we've found over time to establish a good baseline for success.

When someone's considering Facebook ads, buying ads and putting them out there, should they have more than one going at a time or just stick with one and see how it goes? What kind of mindset should they have as they're considering purchasing Facebook ads?

PTO 98 | Social Media Marketing
Social Media Marketing: Video advertisements allow you to build a lot more rapport and a lot more trust.

 

They should definitely have more than one ad running at a time because this way, you can see what ad is performing better and why it's performing better. Let's say you run two ads at the same time. With one ad, you're using a picture of a knee and the second ad is you're talking about the back. Maybe the cost per lead with the back is half the price of the knee. You're getting more bang for your buck, then you’re going to focus more on the back end and do as much as you can with that.

Do you find that some of your clients are having more success with Facebook ads during the slowdown, COVID-19 because people are more engaged in social media and Facebook itself?

The cost of advertising is definitely cheaper because a lot of people have quit and dropped out of the race. That leaves room for people who are still willing to try, adapt, and do new things. It gives them more breathing space since everything is cheaper. We're still generating increases in new leads. We just have to change up the angle a little bit. Instead of advertising in-person consultation, what we're doing is we're advertising a free discovery call or a free phone conversation, which leads to a virtual evaluation, which leads to a virtual rehabilitation program.

What would be your tip or advice for people to get those leads to convert? Is there some secret or magic that you like to consider when it comes to converting those people?

Number one is the quality of your campaign. Having yourself on video, getting the patient testimonials on video and putting that into the ad. Also, calling out who it is you're looking for. The pain that they're having, putting down into the text, and stepping into their head and into the conversation that they're having will not get you that qualified increase. Number two is when you do generate that inquiry, you can't wait three days later to call them. You have to try and get to that inquiry right away. Setting up notifications when you generate that lead and having someone in charge of that process and calling them right away when they're still hot, still super interested in what you have to offer, and that conversation is still going on in their head.

The cool thing about you is we talked a lot about getting patient referrals and leads. Sometimes, those leads take multiple touchpoints. It's not common that you're successful with just one touchpoint and the patient converts. That's why it's cool that you recommend more than one going out at a time. You can get your Facebook ads down to a certain locale, community, and demographic. Once you develop that community, then you can hone in on the issues that are arising in that community. Your content and your output can be specific. That's when it seems like it's more powerful in the capabilities of converting the increase, would you say?

If you’re advertising to somebody, they want to be the hero of their own story and you want to be the guide. Click To Tweet

Definitely.

Have you also used any of this for recruiting purposes? Because I see the capability of physical therapy owners using Facebook ads to recruit for other physical therapists, especially when a lot of physical therapists are out of work to recruit physical therapists via Facebook ads. Have you done that in the past or do you see the possibility there?

I've done a little bit in the past as a small test but that didn't work out too well because we're just targeting like a small population. The cool thing with Facebook is you can target by what they put in their Facebook profile. If they put physical therapist, you can target specifically only physical therapists that live in this specific city within 30 to 40 years old, if that's the age range you're looking for.

Can you also advertise to a certain locale or can you advertise the multiple states in your region?

Yes, you can choose exactly where you want the ads to show and who you want to see the ads.

I bring that up because I see that as a potentiality, even though you haven't done a lot of it yourself. It's an easy crossover to say, “I can use this to not only get patients, at least leads and subsequent conversions, but I also could use Facebook ads for recruiting purposes and that would be cool to try out.”

You have to keep in mind that the person that does have that job title, physical therapist, is probably already with another company. You have to create an angle and an offer that would attract someone who's already working for someone else, and go from there.

You've shared with us a ton of stuff about Facebook ads specifically. Is there anything you want to add or anything that we didn't cover that you would recommend people consider when they're putting out Facebook ads?

Something that people can consider is number one, for $1,000 in marketing budget, they can generate about 100 phone numbers of people within five miles from their clinic who have things like back pain, neck pain or any or any type of chronic pain. They can get them interested in a consultation with one of the doctors at the clinic. The next time maybe someone thinks about buying coffee or buying a sandwich at a store, that $5 to $10 could be spent or invested into Facebook ads and could generate you a patient that's worth $1,500 or $2,000 and get you 2 or 3 more referrals. Keep that in the back of your mind. That's the power and the potential of what a Facebook ads has to offer for clinic owners.

PTO 98 | Social Media Marketing
Social Media Marketing: To create great content, put yourself in the shoes of your end clients to know what it is that they really want.

 

In Medical Patient Referrals, you don't just focus on Facebook ads, but you also have some back-end stuff, whether that's an email marketing campaign for every lead that comes through and also text messaging campaigns to past patients as well.

Marketing is only as powerful as your sales process. If your sales are weak and you're generating all these leads, but you have no idea what time these leads are coming in, not recording any of the calls, not getting back to them quick enough, and not following up, it's so much potential being wasted. What we've done is we've built out a solution where as soon as the lead is generated, it gets populated in your dashboard and your whole team gets notified. They get added into this email and text sequence where for the next 2 or 3 weeks, they're getting testimonials, content, and value sent out automatically.

If someone does schedule someone from Facebook for that evaluation in the office, then my system will know and then it'll send them reminders leading up to that evaluation. It helps with the no shows as well. After someone comes out of that evaluation, the system is going to know and it's going to send them follow up emails, asking them about their experience, how their visit went, and when they want to come back for a second visit. If they already got treatment, want to leave feedback, and leave a review. It's all automated. It makes things so much easier for the clinic.

It's great that you have that because you don't want to get their information and just leave them hanging, especially for three days at a time before you respond back to them. If you can push them into an email marketing funnel and have automatically generated emails that send out testimonials and whatnot, that's when the power comes through. It reminds them that they had some interest, to begin with, and hit those multiple touchpoints that are needed to eventually get them to convert. That's great that you guys automatically provide that. If people wanted to reach out to you and find out a little bit more about you and what you're able to provide, how are they able to do that?

As physical therapists, we can’t use our jargon in advertising. Click To Tweet

They can go to my website, MedicalPatientReferrals.com. Hit the live chat button and start a conversation with me. Get on a call. I can see what’s going on with their clinic and then I can show them the stuff that we have built out. Our campaigns, ads, and the success our clients have seen. If that's something they're interested in, we can work together.

I appreciate your time. Thanks so much for coming on, Edric.

Thank you so much, Nathan, for having me. I appreciate it.

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About Edric Zheng

PTO 98 | Social Media MarketingDropped out of school to start pursuing online marketing. Went from 0-15k a month in my first 3 months of online business, which was publishing books on amazon. Transitioned into affiliate marketing and selling pharmaceutical products (Skin creams, diet pills, muscle pills). Where I learned how to create profitable AD campaigns on Facebook & Google and spend over 2 million dollars in advertising profitably. Which later morphed into taking my ad buying skills and starting a marketing agency in the medical industry helping private practice owners create a profitable patient generation system on Facebook.

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PTO 97 | Marketing For Physical Therapy

 

The way physical therapists market has been affected and will be changed forever because of the COVID-19 pandemic; it's forced to go digital in the way we treat and connect. In today's episode of the Physical Therapy Owners Club, Nathan Shields talks to Tracy Repchuk, a multi-awarded pioneer in digital marketing who has worked with social media, branding, and websites for over 25 years. They discuss the ways physical therapists can market for the better and learn from this slowdown. It's time to turn our attention to digital.

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Marketing For Physical Therapy During The COVID-19 Crisis And Beyond With Tracy Repchuk

I'm excited to bring on Tracy Repchuk. She is a marketing expert and I've met her a couple of times and I've seen the work that she's done, especially at this time during the Coronavirus crisis. It's important to recognize the importance of the marketing that we're doing to sustain our clientele and stay in communication with them. I thought it'd be important to bring her on. Tracy, thanks for coming on. I appreciate it.  

Thank you, Nathan, for having me. I'm excited to be sharing what's happening out there.

If you could let us know a little bit about you, what you've been doing here and also what you're doing nowadays to help private practice owners with their marketing efforts?  

I started a software company at the age of nineteen in 1985. I've been in technology and in marketing my entire life. In 1994 before it was even the internet, that's when I was doing development for banks, JC Penney, Walmart, the Lottery Corporation and large corporations because they didn't know what this was. I knew when I saw it that it was a future, that everything was becoming this. I was an extremely early adopter. In 2006, I went all-in on internet marketing and exploded. I moved from Toronto, Canada to California because I knew this is where the market was at that time. It had not been accepted yet in Canada. It's interesting though because this is an example, what we're going through, in a way was going to happen. The virus accelerated it, is what ended up happening. We were all going to be online in some bigger way. It rushed it by 5 or 10 years. It's turned into a disrupter. Uber and Lyft was a disrupter for taxis, Redbox and Netflix blew away Blockbuster. By the time 2000 came around, those that did not adapt to the new technologies, clung to the Yellow Pages, they perished. They're gone.

Normally, this type of thing has been localized or niche-specific. In this quite case, it's global. It's a planetary reboot. The world will be new. You're going to need to adapt rapidly. That's my excitement quite frankly because everything I've been trained for is happening and what I can do for companies, restaurants, retail, physical therapists, chiropractors, yoga, Pilates. Anyone with a physical location, it's time to take a look at where to go. I've been talking about what you do and where you go for years now. We're right and ready to move into this new era.

It's interesting because this shouldn't necessarily be a pause for a lot of the business owners out there, but rather a reset and consider what you've done and what you need to do differently in the future. If your business is the same coming out of this as it was going into it, then you've not taken advantage of the opportunity. I don't know how well you'll survive going forward. It's a great message to share like you're talking about for physical therapy owners to consider how they can take advantage of telehealth services. How can they sell their services on digital platforms and social media platforms? There's a lot of effort that should be looked into putting our businesses more digital and not rely on the brick and mortar. That's hard because as physical therapists, we want to be manually engaged. We have to recognize that there is a market out there for the other things and we can take advantage of it, frankly.  

PTO 97 | Marketing For Physical Therapy
Marketing For Physical Therapy: We can add all of the technologies that exist for us to leverage and build a more systematized and streamlined infrastructure online.

 

What's interesting is one of my specialties is to systemize, streamline and scale. When you only have a brick and mortar environment, scaling often involves high costs and expense as well and you're carrying huge debt loads. The beautiful part I'll say about what is occurring is we can add all of the technologies that exist for us to leverage. We can build a more systemized and streamlined infrastructure online. That's going to help you scale and make more money without necessarily adding buildings or offices unless you want to. It's great when that is a choice and not the only route so that you can figure out what you want to do. How do you want to make money going forward and how do you expand?

To me, I know it's an extremely exciting time because it's making companies think out of the box. What I love about physical therapists is you are built for health. You want to help people. You want to make sure that they understand how they can repair an injury or how they can get more mobility, especially without drugs. It's the savior of the planet from what's happening now. Two things the online environment can give us, and one is exposure. Instead of us having that localized message office by office, when the entire PT industry or people start to shout it from the rooftops what you do. It's an ambiguous think quite frankly, and people think it's specialized that it's not for them.

I came into the physical therapy world when my mom had a huge incident that resulted in her entire back crumbling. She had the entire thing repaired with pins and rods and through numerous surgeries and then ended up in the hospital for seven months doing physical therapy, during which time I stayed and assisted her. Hence, the beautiful part that I had an online business and could do that has that gift of time. The other part was what respect I built for what you did. That's where my passion became, I need to get out the message about what you do. That's where I entered into the physical therapy arena and started to help physical therapists to move online. This is what we'd be doing, but now it's game over. Get on now.

I like the points that you brought up and that is number one that spreading your message or at least relying on the office space to grow your business can be much more expensive and time-consuming and energy-consuming. Whereas, if you expand more digitally, it doesn't cost as much to expand and grow. Number two, we can market directly to the consumer if we take advantage of it the right way and not rely so much on physician referrals but rather go directly to the consumer because all 50 states have direct access in some form or another at this time. We can bypass the physician referrals and go directly to the consumer and say, "If you have an acute injury to your back, because you're a weekend warrior, come and see us.” For some reason, chiropractors are able to get that message out, but physical therapy hasn't been able to do that. If we work together as a group during and after this crisis, we can get that message out via social media, through digital marketing, what you have it, and help people understand that you don't have to go to see a doctor to see us. You don't have to have gone through surgery to see us. We can see you right now. That's a message that you can get out even for those people who aren't affected by the virus and then sustained as we ramp back up.  

We were all going to be online in some bigger way. The virus just accelerated the process. Click To Tweet

To me, this is part and parcel of a combination of how do you get people no longer addicted to opioids by spreading the message that there is an alternative. You can get natural-based therapies that most people are not aware of. This is the reason that prescription drug abuse, in particular, happens because people don't know. "If I get adjustments or if I do this or get a correction on an injury, I don't need to be in that pain." The biggest problem is when they choose that the alternative route is they don't want to end up out of pain. All they end up is masking it and it never gets repaired. It's important. Honestly, this is the greatest catalyst you’ve got for the PT industry and my other passion is nutrition response testing. Anything that deals with making the world a better place and helping a person to get healthier without any introduction of alternative elements other than your own body telling you how to heal.

I like how you brought that up because it made me think of two things. I thought this is going to be good for our profession in that it's going to force our hand into telehealth services. Our profession is going to be changed forever because of that. We've been forced into some telehealth services to a greater extent than we were before. Number two, this is going to force us to get our message out digitally that physical therapy owners, in general, are behind the curve when it comes to modern technology use and social media use. Some people have done it well, but I would go out on a limb and I  think it's a big limb and that I don't think we've used it to our capabilities to push the message that we can see you directly, that your acute issues can come to us directly. We can see you without a doctor's referral that is forcing our hand in direct to consumer marketing. I don't think I realized that before talking to you. I did regarding the telehealth, but it's going to force out the physical therapy owner's hand to be more aware of their direct to consumer/digital approach. As you're working with somebody, where do you start? Do you start with the website? Do you start with their Facebook accounts or their Instagram or all of the above? Where do you start initially? 

I’ll tell you where I normally start and then I’ll tell you the COVID-19 start. It's an important piece and I'd be talking about that again for years. It’s with the landing page and the list building. We need to focus on accumulating the database because that is going to be your greatest asset. It's also the reason that it's important is as you're now going to expand through social media, we don't want to expand through social media unless we have somewhere to send them. It has to be the landing page. We have to be list building so that we can do email marketing. Why is that important? It still has the highest return on investment. It is the way that I'm advising clients now is to get emails out to your database and triple your communication to them so they feel heard and taken care of. They're in worry as well, especially if they do have injuries. They know that they should be doing something and they feel like they can't.

PTO 97 | Marketing For Physical Therapy
Marketing For Physical Therapy: We can get more people no longer addicted to opioids by spreading the message that there are alternative, natural therapies which most people are not aware of.

 

It's one of the original technologies that have to become stable and should have been years ago. The other reason I love landing page technology, especially for PT's, is how we can create what we call the lead magnet. This gift, which I've been creating for many physical therapists now, is an educational tool and that's what they need. The five ways to whatever to get off of opioids or the five best strategies for pain reduction of your back, your knee. We pick the target market, we create an asset to give. The beautiful part about where we have gone is all of that marketing at that time was kept local.

You can grow at a certain rate. There are only so many people that might need you. Now with the introduction of this global pandemic and the fact that we should be out in a bigger way, it doesn't have to be local. It's great when it's local. I do a lot of the strategies to focus on that, but the bigger picture is the more people that have this gift or guide and content in their hand, the more people will understand what physical therapy as a whole is. This is how we elevate the entire industry at the same time as you're moving into a position of leadership and authority because you're the one delivering this information. We add fuel, which is social media. We start on Instagram and then we start on Facebook.

We create a community on Facebook. What I love about Facebook is it is the platform for community building. You can become a leader, not only in your community, which is wonderful, but overall for maybe a specific thing you deal with. I have physical therapists, some focus on sports injuries, some focus on back injuries. If you have specific needs then you can build an entire platform around that and attract all people. There are two billion people on Facebook. There's your entire market. You have many people to draw from. This is how we're going to educate.

I say, "Let's get the landing page and list building in place." What I'm saying to people now is we need to get the Zoom technology in. We need to get you in front of it and have you doing Facebook Live and we need to start talking telehealth. Both of these pieces have to get in rapidly so cashflow continues and you become the stable datum in your marketplace as that person of authority that says, "Welcome, everybody. I understand." Originally you're talking to people that are in your community, but as you grow and as you start to do more Facebook Lives, you can say, "We're going to be talking about how to remove or eliminate a back pain that you have from sitting too much."

You can start joking with things. "We're going to help you with your Netflix knee." I don't care what you're talking about. Don't be afraid to connect it to what most people are ending up doing and start to outflow. The beautiful part is if we do this in conjunction with the landing page, we're database list building at the same time. I have even, not just for my clients but for myself, quadrupled my outflow. I've been doing a Facebook Live almost every single day since we were put into lockdown and quarantined and my numbers have exploded. That's what can happen for every business that turns around and does it.

We are experiencing a planetary reboot. We need to adapt rapidly as the world changes. Click To Tweet

I've been pushing my clients and my readers to make sure that their promotion and marketing don't suffer and decrease. That's the last expense line you want to rid of. I like how you're saying at this point where you would typically have them go through a landing page process and develop that all out. It's time to move fast and quick. The best way to do that is to get onto social media, develop your community. When you say list building, you mean collecting email addresses essentially. Probably the quickest way to do that is to create that Facebook page or the community. You should have a list of past patients that you can invite to it. You can maybe boost the page or something like that if you want to, but develop that immediately with your past patient email list, that database to begin with. Then build on that by inviting more people and get them to create more data or more content if you will and start developing more and more lists. That's a way that you can immediately start building up that list of subscribers. 

Here's the cool part. As you do a Facebook Live, especially if it's content-driven, you're going to talk about the knee, the back, the shoulder, whatever. Now you have content. The average Facebook Live, let's say it's 20 and 30 minutes, you can break that apart into over 200 pieces of content. Even if we only do one thing and that one thing is to take the whole video and move it into YouTube. If you move it into YouTube and you do the necessary keyword optimization, here's the reality of YouTube. All of the deals in the world aren't going to be found if you do not search engine optimize with keywords. It's a critical and key part. It's exactly what I've been doing with my client. All we're doing is taking their content to YouTube and we're keywording it.

In general, I'm getting on page one of YouTube for searches in the top four spots when it's properly keyworded right off the bat. There is no loss in that content. Let's say you did a Facebook Live and you're like, "Nobody was there." No worries. One is going to replay on Facebook. Facebook Lives, it's going to continue to replay it for you and then we're going to take it and now build an asset from that. That content, we can pare it down even smaller. You can start thinking membership site. You can start thinking added-value for clients. That's what we're doing with one of my clients, which is a Pilates studio.

When we were shut down in California and she was shut down, she was like, "How on earth do I pay my rent, pay my mortgage?" She had eight staff. The rent on her studio was enormous. For some of the PT's, you're in the same boat, you have the equipment, you have studios and you have staff. We went into crisis management at that point and that is, how can we get money in this studio? The immediate answer was getting a Zoom camera in front of her and build out the website so that she could take money for classes immediately. We were recording those classes by Zoom.

PTO 97 | Marketing For Physical Therapy
Marketing For Physical Therapy: We don’t want to expand to social media unless we have somewhere to send them. That’s where the landing page and database building come to the picture.

 

They were going out there and then we were taking that same class, putting it into a replay page as an added bonus for purchasers and then we were taking that class and putting it into a membership site. Now, as people go through, they can buy a week's class, they can buy a one month class and/or they can buy access to the membership, which means they get access to every replay on Pilates in this situation. It has exploded. She went from, "How am I going to live?" to one week later, she had 65 people going through her classes, which was more than the physical studio because of the volume you can deliver to in that situation. It's great when you, one, know that you have the technology to help somebody in that situation, but two, you can see somebody who was extremely distraught. I'm sure there are many people out there like that. This technology will work for you, we just have to think out of the box on how.

How does that cross over to physical therapists? What could they do? What content do you recommend that they come up with that kind of growth if you will or accelerate maybe their digital presence or their online content?

We have physical therapists that are leveraging Zoom for telehealth. They're leveraging Zoom for Facebook Live. At first, your Facebook Lives are targeted at your current database and they're like, "This is what we're doing. This is what the office looks like." After that, you want to start taking a look at what is a niche you can talk about. Generally, to make money, you need to go nine miles deep and an inch wide. You'll come out as a physical therapist and let's say you specialize in athletic rehab. Let's say you specialize in back, sports, shoulder or golf, whatever it is. If you have that particular niche, I will start to talk about that. That's how you're going to attract not just your PT client-base, which you've already moved into there, but now you're going to attract those people that are interested in that particular topic. How you do that is not just through Facebook Live. You'll set up events because events on Facebook get promoted. Somebody sees, "Here's an event coming up on Facebook and it's on the three tips to increase your running speed." "Great, I want to know that." The PT can talk about that.

In the beginning, that is a lot of outflow without monetary income except for telehealth, but what I like about that is the power of positioning and the power of educating on what physical therapy is. Plus now, as the people start to follow you and you get 40, 60, 100, 200 followers on Facebook in your community, all you have to do at that point, and I always pilot everything before we build it and say, "What if I opened up out a community, a membership and you paid $47 a month and I would continue to do education and assessments, whatever you want to put in there? Who is interested?" If you get ten people that say, "I would like that. That's great." I always do it based on ten. You get ten people that say, "Yes," then you start to build and honestly the build starts simple. You don't have to fill it with 52 months of content. You're going to be building the content as they're in it. They're going to pay you to build the content. This is where social media starts to come into play. Before, more social media, more followers, we couldn't capitalize on monetization at that point yet, but we sure can when we have a membership site built. Now, we can funnel them in through that and start to build up a community of people that want our results that are running, better golf, health, out of pain, whatever it is that their goal is. This is what your membership community will start to focus on.

Digital marketing will work for you. You just have to think outside the box on how. Click To Tweet

The alternative to that is building a course. You want to build a five-module course on that. Whatever route you choose, the beauty is it's scalable, salable and evergreen, which means Facebook Ads, Instagram Ads. More content to drive to this marketing media that you're building is the ability to create six figures without any extra cost to whether it be your office infrastructure or more staff. It's what I call a plan B. Plan B means if you were pulled out of the workplace, if you had to take care of your parents, like what happened to me, or if you had to take care of a family member, whatever. If you had to stop, would it be sustainable? With that infrastructure of the digital environment in place, the answer is yes. If we build this and rapidly and something like this occurs again. It's occurred how many times now? At least seven. I was in Toronto during the SARS. It was similar to this only it wasn't a global pandemic. It was in Toronto. We were the ones that were shut down and into lockdown. My business already went through a year of what we're going through right now. I knew and I did at the same time make these assessments and that's why I have so much experience on how the heck do you go digital because I needed plan B way back then and that's when I started talking about it. It's time to get plan B in place. I love to help people do those.

My biggest issue has always been creating content. I'm not one that can spin out content. Is that something that we would expect out of you or any marketing specialists that we hire on at this time?  

You don't need us to create the content. You need us to take that video, SEO it on YouTube, and then build a membership site, put the video in the membership site, maintain the infrastructure, the communications, and email marketing. You have the PT knowledge that already your marketplace is waiting for. All you do is seven bullet points before you start talking and you already know what you're going to say and there is the training that you're giving them within the membership site. There is no need to get nervous about the content you're going to give or whether you know what you're doing. You know what you're doing. You can demonstrate things on a doll, whatever it is you’ve got to do to show somebody how to do something that can help them with whatever outcome that they're looking for. The knowledge is all in you. The marketing and technology are not and that is a piece we handle.

It seems like it goes without saying that you're pushing video over written, a blog or anything like that.

It is 2020 and beyond blowout. More video is consumed and uploaded than in the last 30 years of all three major networks. All search is coming through the video line. People are even bypassing Google now because they don't want to read. They want to watch a video because five billion people are watching on their phone and consuming content and reading is a pain in the butt on the phone. We are media watching junkies, Netflix, Hulu, Amazon Prime. That's what's happening. Media is key and the good video combined with what Google is looking for and what the YouTube search engine is looking for, which is keywords, is your secret sauce. That's where you're going to punch to the top for everything someone's looking for. That's it. Once you've done that, you can start to embed selling in your videos that are on YouTube by saying things like, "Go to my landing page, go to my channel, go here,” everything. There's this circular way of optimizing every piece of content you produce, driving them ultimately to a membership or a course.

PTO 97 | Marketing For Physical Therapy
Marketing For Physical Therapy: If you have a specific niche, you can build an entire platform around that and attract all sorts of people there.

 

Not to get too much into the details in regards to video, but is there a certain amount of time that is optimal, as a 15-minute versus a 30-minute video? Backgrounds like this, does that matter too much? I'm wondering about any details that you recommend if someone is to post a video on social media?  

It depends on which social media platform. On Facebook, they like the longer the better. That's how you can get more people watching because you're constantly going to be fed through the news feed while you're still on. If you're a blip on the news feed and you're off, that was it. That was your shot. The longer is better on Facebook. Why? Let's say you're doing a training video on YouTube because we're going to take that content. Thirty minutes is fine on YouTube. The average person is consuming 40 minutes at a time on the YouTube platform. This is only going to go up during this time. That was before.

We know on average we can do 40 minutes. My videos are 40 minutes. YouTube wants over ten minutes. If you have a quick key tip, then that's 3 to 5 minutes, something fast. Let's say somebody had a headache and you're like, "How to get rid of your headache in two minutes?" That could be a video. You touch here and you do this and you put whatever. I only know how to translate it so someone pays for it. It all depends on what you're doing. To me, most of mine are longer and highly consumed from that perspective. You've got content. What do we do? Now we take that video and we embed it in the blog post, we're hitting another platform, then we do have Instagram on it. We do a LinkedIn on it, and then we do a Facebook promo on it.

It's a constant circle of leveraging content that you've already created and making sure that it can get consumed wherever your person might be. It’s because LinkedIn is B2B, it doesn't mean there are a lot of people incorporate suffering from physical therapy needs. It's interesting. It’s the same with Instagram. Even though that's the younger platform doesn't mean that a Millennial who's been jogging or playing tennis doesn't need a physical therapist. That's the beauty of what you do. Cross-platform promotion needs to happen so we can find the sweet spot. Once we know it, that's where the fuel pours in that area.

That's why I'm glad there are people like you out there because doing all of that blows my mind. I don't want to touch it. I don't want to put in all the keywords. I want to do my thing and then give it to someone to work with. Either that person is on your staff or you hire it out to someone like you who's a specialist at it. I'm sure the dollar put into you will go a lot further than having someone in the house through it unless they are super expert.  

This is not a time to shrink and go into survival mode. You need to market and promote more than you ever have to rise to the top. Click To Tweet

There's the other thing. Let's say you had a social media person on staff. We can work with people like that because what they're often missing is strategy. They're like, "I'll do this or this is a cute post." We're watching too. We have to know what all the trending keywords are, what all the trending hashtags are and we need to make sure that all posts optimize five different sets of hashtags for everything that's going on. They may not know that, but when they're talking about that, then there's like, "I understand what I need to do." That helps the office as well. For those of you who do have staff, but perhaps they need a little more guidance, that's where we often come in. We teach them specifically on what they're doing to help you and then we move either to another part of the company or you don't need this anymore, whichever happens.

A lot of times you lean on that social media person to be your strategist when maybe they're saying, "Here's a cute video. I'll post that. Here's a recipe that our audience might like,” and post that. It's what anything that we put out there is okay mentality instead of being strategic and focused on the content that they produce.  

That goes to part and parcel of increasing your conversions, increasing your brand and your elevation of authority and influence comes strictly from the strategy that goes behind the post.

If people wanted to get in touch with you and see what you provide and how you can help them, how would they do that?  

There are two ways. You can check me out at TracyRepchuk.com. You can check any social media platform with /TracyRepchuk or you can take a look at the funnel, what I want you to have. My landing page, which is FastActionResults.com and you'll see the process. I bring people in, I give you a gift. At that point, if you need to schedule a strategy call so I can take a look at what you've got, where you're bleeding and how we can help repair it, then that can happen immediately. You click and schedule.

Thank you for your time. Is there anything else you want to share with the audience? 

The thing I would share as a final note is you need to market and promote more than you ever have. You said it at the beginning, Nathan, and that this is not a time to shrink. This is not a time to go into survival mode or hunkered down. You have to do the opposite of what everyone else is doing so that you're the one that rises to the top and becomes the cream. The only way to do it is to get out there bigger than you ever thought you would.

PTO 97 | Marketing For Physical Therapy
Marketing For Physical Therapy: Keywords are the key to social media marketing. That’s where you’re going to punch to the top for everything someone’s looking for.

 

Maybe a lot of market owners have time now if they have slowed down and/or shutdown. If you've got time, now is the time to consider maybe your digital presence and that strategy a lot more.  Thank you for your time, Tracy. I appreciate it.

Thank you, Nathan. It's been great.

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About Tracy Repchuk

PTO 97 | Marketing For Physical TherapyTracy Repchuk leads and empowers you to develop a freedom-based business by systemizing, streamlining and scaling to success

> 7 Time #1International Bestselling Author including 31 Days to Millionaire Marketing Miracles from Wiley Publishing

> World-renowned speaker in over 37 countries including China, Dubai, Brazil, Africa, Australia, Singapore, UK and more

> Award winning entrepreneur, writer and speaker since 1985 when at the age of 19 she started her software company

> Over 20 awards including from Senate, Assembly, the White House and President Obama

> Pioneer on the internet developing brands, websites, SEO and now social media since 1994 and currently serving on the Forbes Coaching Council, Amazon Influencer, and Linkedin Advisor programs

> Featured expert in over 22 National and Local TV as a trusted resource for technology, internet and social media including ABC, NBC, CBS, FOX and featured in 3 motivational movies

> Runs her own 501c3 foundation to help underprivileged women to gain life and business skills so they can be independent and run a business from anywhere with confidence

> Global leader in strategic thinking for increased market reach serving thousands of clients around the world to help you reach millions with your message.

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PTO 76 | Direct To Consumer Marketing

 

If you consider marketing to physicians "Marketing 101" for PT owners, then obviously, marketing directly to consumers (potential patients) would be "Marketing 102." And if Marketing 102 for PT owners were a college course, Matt Slimming, PT would be the professor. Recognizing the changes happening around him - POPTs and hospital network consolidation, referrals from physicians are down 50% over previous years, etc. – Mark realized that he needed to access patients in a different way. Whether it's improving SEO, getting patient reviews, or utilizing social media ads, he found that there is a greater pool of patients available to him when he markets directly to the surrounding community, plus he won't have to rely solely on the doctors to keep his eight clinics steady busy! It may be a new concept for some of us, or maybe some of us have tried it and not seen the results. Listen to what Matt has to say and maybe he can guide you to online marketing strategies that have been proven.

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Listen to the podcast here:

Marketing 102: Direct To Consumer Marketing With Matt Slimming, PT

I have Matt Slimming out of the Greater New Orleans area. Matt is uber-successful. You can tell he's a transplant from Australia. He came to America and has established and grown his physical therapy clinic to eight clinics at this time, I believe. He's doing something right. Matt has come up against some of the similar issues that we have as independent clinic owners in obtaining new patients with as many physician-owned physical therapy clinics that pop up, hospital networks that have gained ground in many urban areas. Based on the inspiration of an episode I did with Mike Bills, I'm excited to talk to Matt a little bit more about online marketing and getting your patients not from physician referrals, but focusing on direct to consumer marketing and how he is able to get more patients that way. Matt is going to share with us what has been successful for him in his online marketing and social media marketing approach that has led him to be successful and continue to grow and get new patients in this current environment. Let's get to the interview.

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We have Matt Slimming, Founder and Owner of STAR Physical Therapy in the Greater New Orleans area. First of all, I'd like to thank you for coming on.

It's a pleasure, Nathan. Thanks for having me.

Matt, if you don't mind, I've heard great things about you. You've got a great presence within the New Orleans area, eight clinics. Congratulations. Tell us a little bit about what got you to this point where you've been able to grow to where you are.

What's allowed us to move forward was the struggle that many clinics have of suddenly finding themselves competing with an ever-increasing amount of pops and hops and start-up clinics coming from every nook and cranny. It happens to a lot. I was speaking to an owner in North Carolina and experiencing the same thing. Suddenly, they're everywhere. They seem to love to jump into the nice areas that people want to move to. Chances are if you're in a nice area, it's either undergoing a dramatic increase in competition or it's about to. We found ourselves in that situation where we had at that time three clinics and we found that we weren't growing anymore. We were starting to slip backward in one of them.

How long ago was this?

This was about 2010, 2011.

Were you starting to see some of these pops in hospital networks coming in?

Pretty aggressively. Also, our community that we're in, which is on the Northshore of New Orleans, our main clinic early on was designated as the place that New Orleans was growing to. Therefore, all the business owners wanting to get there before the crowd got big. We saw an influx of new businesses, the new PT clinics. We had to work hard at marketing. A couple of years later, it was about 2015, direct access became a reality in Louisiana. In 2011, we started the market aggressively and we started to do a little outside marketing. In 2015, we realized that we now have the freedom to market in a way that attracts the direct access consumer. Since then, we've been studying online marketing. Gradually, our business has shifted over the years to where that's the main focus of our organization is online marketing to gain the audience and the new patients through that media.

It's interesting that you say that because in 2014 or 2015, you got the direct access opportunity in Louisiana. It sounds like you guys jumped up on that quickly. It seems like a lot of physical therapy owners drag their feet when it comes to marketing direct to consumers. What do you attribute that to? Why aren't owners taking more advantage of direct access in their states? All of us have direct access at this point. Some may be better than others but we do. Why aren't physical therapists taking advantage of that? 

In some communities, it is a concern that they might ruffle some feathers and that they might offend referral sources. The orthos have been against direct access with good reason that they would perceive that they might lose market share. We understand that. A lot of physicians in a lot of communities hold the belief that we shouldn't have direct access, that we don't have the skills and knowledge for that and the education for that. Because of that awareness, a lot of good PTs with great relationships with physicians didn't want to rock the boat. Why mess with something that's doing okay? That combined with the, "How do you do that in a way that works?" A lot of guys tried a few things, it didn't work for them so they said, "Forget that. We'll keep on rolling."

PTO 76 | Direct To Consumer Marketing
Direct To Consumer Marketing: We should not keep someone from getting the care that they need that might be better for them.

 

It's tough to swallow because like you said, there's not only competition coming around every clinic out there but there's also the fact that physician referrals are plummeting. I don't know about your experience, but my experience is if a physician is referring out to physical therapists nowadays, the majority of them are saying, "Here's the prescription." They’re giving it to the patient, "Find a physical therapist that you like." They're all good. We're commoditized in their view. We've always had that subservient attitude. We want to be subservient to the other healthcare providers and not ruffle feathers.

That's a different conversation for a different day about my issues with that but a lot of it goes to how do you do it? Do I now become the local car dealership that posts advertisements for other chiropractors that are doing it? How do we do it effectively? How do we do it in a smart sense that makes us look well but also shows that we are the experts? Maybe there's a part of that too where we haven't necessarily been the gatekeepers in the past. Are we prepared to be the person that sees that for that patient right off the bat because they've typically gone through somebody else first and been screened out?

To answer the second thought, we all deal with initially the idea of, "I have much more responsibility now. I've got to catch those red flags or yellow flags. I've got to make sure I know what I'm doing." There are a lot of PTs, and some PTs in our group, that we had to educate on how to do direct access well. That's the first thing we have to be good. We got to know that we're not going to hurt someone, that we're not going to keep someone from getting the care that they need that might be better for them.

As you're dealing with more direct access care and maybe as you bring on the physical therapist onto your group, especially new grads, is that one of the first things you're doing in your training with them? Are you saying, "If we have direct access now, these are some of the things that you need to sure up?" Are you doing some training in that regard?

We don't have our new PTs do much direct access work initially. It might be months that they're working with us before we allow them in that process. What we find is most PTs have the education to the DPT where they're effective at doing direct access. I didn't know that when I first came to the US. I went back and got my doctorate and that's what allowed me to have that knowledge. Most PTs now, they're coming out with good knowledge. There are more nuances perhaps that we have managing and massaging the direct access than just the clinical stuff.

We can do it. If it's a hurdle or it's a fear, it's a matter of training yourself a little bit more and getting ready for that opportunity so that as you do the marketing direct to consumer, you show yourself well. You become that actual gatekeeper and gain confidence. It's the repetition and the work that breeds confidence. The confidence doesn't come first.

It's a good point, Nathan. There are two groups, those guys who are confident and happy to be putting it out there and then the other guys who are just as great skilled as a PT but don't feel like they are the expert. The reality is that PTs are the experts at musculoskeletal problems from a broad area. We need not be concerned that, "I'm not the smartest PT in my community. There are guys out there who have more initials after their name. I shouldn't be the one doing this." No. You know enough to help people better than most of the physicians in your area, probably would initially is what you can do for them. We always have an obligation on ourselves to be intentional about helping our fellow man and getting the word out there about what we can do.

You guys had three clinics back in 2010. I imagine you might've grown a little bit here and there between then and 2014 and 2015. You've grown to eight clinics. Do you think most of that has come from your direct to consumer marketing? 

A part of it, I wouldn't say most of it. Without that direct access marketing, we wouldn't have had the confidence to open other clinics. We know that we can be successful with zero physician referrals. We can still make it work. It's nice to have that behind you to say, "This will still work." We'd be foolish to only rely on that. We're all in communities. We all need only to be good neighbors and we all need to collaborate. One of the nicer things about direct access and being successful in online marketing is that we can now refer to physicians much better. That's a treat when you offer pods in the area looking to chat with you because you sent them a couple of patients last month. That changes dynamics entirely and it's a refreshing place to be able to live.

What are some of the successful actions that you can share with us that you're doing online and developing that patient referral base that is separate from physicians?

Because most states have direct access, it is a must for PT owners to take advantage and market to their local communities. Click To Tweet

A lot of people start and try something. It doesn't pan out well until they say, "It's not for me," which is unfortunate because in every community, there's a way to do it that works. The first thing is we have some real strength as physical therapists. We are the good guys. Patients that leave your clinics will think of you as a friend. If they see you in the supermarket, they're going to give you a high five. They're going to introduce you to their wife. You are the good guy. You didn't bilk them, you didn't even charge them out the kazoo. You're reimbursed poorly as a physical therapist. No one thinks you're tremendously paid. You don't have that burden to deal with. We also can share comprehensively what we do and what we know.

Those two things are a real strength because a lot of other disciplines in healthcare, they’ve got some stuff under their hood. They cannot afford to be comprehensively honest and transparent because there is some weird stuff. I don't want to point at any particular type of doctor but we've got an opioid crisis. That would be an example of some stuff under the hood that might be hurtful. We haven't got that as PTs. With those two things in mind, we can be confident about marketing online. Being transparent about who we are because we're the good guys and what we know because what we know works and it doesn't come with side effects.

That's the base that we work from. We have to couple this educational approach because you can feel free to educate along with a degree of sales knowledge. It certainly isn't good to go out. They're good enough at least to go out there and tell what you know because you may help some people, but the chances are people aren't going to act on what they learned from you through some online medium. They're only going to get the help they need when they see you in the clinic. We have to couple that with some direction, some sales techniques that will bring these people into the clinic and that's in the form of a funnel. If you can imagine a funnel that you've got all these people that join your funnel at the top of the funnel and your goal is to get them through as many of those folks through to be patient as possible or at least of those that need your help.

You only want to help those that need your help. We don't want to be serving people that don't need our services. We have this funnel. You want to attract a broader group at the top of the funnel and you want to keep as many of those coming as a patient as the need to. There's a lot that goes into that funnel. First of all, I will say you don't want to be marketing physical therapy because when you ask someone, "What would you go to a physical therapist for?" you get all kinds of answers and it won't be negative. It won't be back, knee pain, shoulder pain. We've got to be approaching them with, "You've got this problem.” Let's say it's knee pain. You want to have your marketing be focused on how you're going to help that knee pain. From there, you draw them in with some good information.

We have a process that takes those people in through phone calls, texts, emails, and then possibly through some other ads going back to them to educate them a little bit more. Once you identify them, we call that retargeting. You draw these people through the funnel by more and more education until they feel A, that they are educated about what's going on a little bit and about how you can help them. B, they trust you because they've heard from you and they've seen your stuff in numerous channels, but they've also heard from you, your different ways. Now, they're starting to trust you. Once you've achieved that, it's much easier to go that last little step of the puzzle to say, "Come on in to the clinic and I'd loved to meet." There's a long process, but that works.

A couple of things regarding your process. What is the percentage? Is it 10% to 15% of people that need physical therapy or would qualify for physical therapy get it? Maybe it's even less, like 5%. When you're considering marketing to the consumer or the community, physical therapists are fighting for 5% from these physicians. We’re all fighting over 5%. If we could open up our minds and get a greater perspective that there's 95% more out there that need our services and what they don't have is that they don't know us. They don't know what we do. They don't know how we could help them. They can't like us because they haven't met us. If someone's going to buy, they're going to have to know, like and trust you.

What you're talking about then is developing this pattern so that you can show them who we are, what we do, like the message that you're sharing. They have to like it or they'll turn you off and they have to trust you that, "This does work." This guy does know what he's doing and I can put my knee and the faith that they're going to help me with my knee in their hands. There are a lot of thoughts to go that are going around in my head as you're talking because this is the direction we needed to go more towards. That is direct to consumer marketing. Take advantage of the direct access and how we go about doing that is education. Don't start with physical therapy because if you say, "Blankety-blank physical therapist is the best rehabilitator in the Greater New Orleans area," it's not going to get you anywhere.

I read a book called Building a StoryBrand by Donald Miller. People don't want to hear how you are the hero. They want to be the hero of their own story. You are otherwise the guide. You're the Obi-Wan Kenobi to the Luke Skywalker, they're the Luke Skywalker. They're looking for their Obi-Wan. If you can set yourself up as the Obi-Wan to fight the evil and get the bad guy, then they can become the hero of their own story. It goes back to a lot of what I hear from marketers is that they don't want to necessarily hear about how you're going to heal their knee pain. They want to know how you're going to get them back to golf or tennis or things that they want to do, a lifestyle.

It's often said that people don't make decisions based on information. They make them based on feelings. That's how most of us make most of our decisions. That's the case with me. We analyze everything, but in reality, we would be paralyzed if we analyze everything to the point of decision. We all do things on emotion. Nathan, it's important to be fit for them to feel comfortable and to like you. Thinking that you will be a good guide where they can say, "Show me the way," what a relief that is for people.

What are some of the successful actions you're doing online to create this funnel of available patients and to maintain them? Are you on social media? Is it email campaigns? Are you using some postcards? What are you doing?

PTO 76 | Direct To Consumer Marketing
Direct To Consumer Marketing: We have an obligation to ourselves to be intentional about helping our fellow man.

 

We're doing work on Facebook and Google and email campaigns. Those are our main ways that we're reaching people now. Our website captures a lot. If you do all this stuff well, it's great for your SEO because it directs people back to your website. I'm a great student of Facebook and I utilize it for work fantastically I feel, but I am not a great partaker of Facebook. I'm not one that can sit there and look at whatever I was thinking now about the same thing or something. My wife tells me that every single lady that she knows is on Facebook. Thankfully, our wives, the ladies, the ones who make decisions about our healthcare, those are the folks that you want to hit. Those are the folks that make good decisions based on their emotions. They've got great instincts. If you can connect in the Facebook world, ladies and seniors are probably prevalent on Facebook, a bit more than younger fellows. It's a great opportunity for us that there's a great group to connect with.

You have to consider it. You and I probably do the same thing. If someone's going to send you a referral to a place, what's the first thing you're going to do? You're going to google them. You're going to see what their website looks like. See the picture. Who's treating me? Do I like that staff member? What does their website look like? Is it easy to navigate? What is your clinic? What does the inside of your clinical look like? If you're considering that person, my wife and I are the same way. If we're considering any vendor that we might want to use, throw it up on some community page on Facebook and say, “Who's a good physical therapist out there? Who's a good doctor for blankety-blank?” You'll get 4 or 5 replies. My wife does photography and she gets business because she's in a group or in different small business groups in the community. When someone on Facebook says, “Who do you guys recommend for some portrait photos?" my wife will come up. The same thing can be said for physical therapy. You're on physical therapy, I'm sure as your clinics, are you doing some Facebook ads as well?

We do a lot of Facebook ads. What connects with people changes all the time. What's working now won't be working very well in several months. With Facebook, there are a couple of keys. The first thing is you want to measure and track every single ad that you put out there. There's a lot of great information that Facebook provides for us. From as little as cost per action you want whether that's a lead or a click-through to how many people viewed it. You can look at likes, all those things. There's so much data that Facebook provides. Whatever ad that you do, you can check and analyze then measure how successful it is.

What we see now is that surprisingly, picture ads are still effective if they're done well. They've got to connect with the individual. What will connect in one community is different from other communities. The key is to be measuring. We'll throw out 6 or 7 ads for one particular opportunity. Let's say we have a funnel that we've put together a shorter resource online and we're trying to direct people to the shorter resource. We know that when they get into this shorter resource, there will be opportunities for them to connect with us through message and through email. They can set up an appointment with that shorter resource. We use seven different ads perhaps for it that will direct people to that shorter resource. There might be 2 or 3 picture ads. There might be a slideshow testimonial. There will definitely be a couple of video ads in there. We make video ads of different types.

The key is to measure every week we feel what's working and what's not. You stop the ads that aren't doing as well until you end up with the best 3, 4, whatever that are killing it for that. It changes over time. It used to be that the talking head ad would do well where it’s me sitting up there on Facebook saying, "Does this problem hurt? Let me talk to you about this problem." It used to work great. People either get tired of seeing the same face or it might be that they're tired of that type of ad. We've evolved into doing video ads that are more creative to them. There are a lot of great ways that you can get a good video that you can create and turn into a compelling ten-second message. It tells the story they need to understand in order to take action and click. That's the first thing. You've got to try different things and every community is different and it changes over time. Measure and get rid of what doesn’t work and keep on finding what's working better and better.

At your size, do you have someone that's creating that content? Do you have a team in place? Do you have physical therapists that are creating some of that content for you on a regular basis? How does that work?

That is my job, Nathan. The creative is me. I'm a frustrated marketing guy. I went into PT by default or something, but I love it. I find that fascinating science is creating an interesting creative. You've got to have that. You've got to have something that jumps out at people. That's my responsibility. We have other people in other paths that we follow too.

I'm not that creative guy. All that for me is like nails on a chalkboard. The important thing to take away is to find that person or get a team around. It might be this past episode that I interviewed Mike Bills. His physical therapists are responsible for creating one blog post a quarter or one article a month or something like that. It doesn't have to be a lot and maybe one video every quarter. They're developing this library of articles and videos that they can repost if necessary along the way so that content creation isn't all dependent upon one person. If it was depended upon me, it wouldn't happen and it wouldn't happen well. For someone like you, and there are plenty of owners out there that are the creative type and it's an outlet and fun and exciting, that's a great way to go but for the guy who might be a little bit overwhelmed, you've got to find, "Is there someone on my team that can do that?" Are there resources out there now? Do you use some other resources out there to help you out?

I can get video from different sources. There are websites where you can find a short video. The tricky thing is you can't type knee pain and there wasn't a video for knee pain. You've got to think outside the box. For example, we had a knee pain funnel and we want always to catch their attention. We've found this great video of different people dancing. This video phrase through had a couple of seconds of five different types of people, old people, young people, hip hop, all crazy stuff. The message was, "If your knee can't do this then you need to do X," which was the next step in our funnel. You've got to think outside the box and find a video that works and uses music that connects with the audience that would match that video.

Are most of your campaigns then diagnosis-based or body part-based?

We're all in communities. We all need only to be good neighbors and collaborate. Click To Tweet

I would say body part-based, not diagnosis-based.

Do you find more certain body parts attract more patients than others? I would assume that your back or neck pain patients or those ads might bring you more patients than others.

It's surprising, back can do okay. What we find is that there are many people treating backs in our communities. There are chiropractors, goodness knows how many guys would like to inject backs whether they be surgeons or guys that usually are surgeons. There are many disciplines that are trying to get onto backs. That's the toughest space to compete in. It's worth doing but shoulders do great. Knees do great. Surprisingly, we've always had a positive return on ad spend but we would think they'd be right up there with backs, but not as much.

Are you also doing Google reviews, Yelp or anything like that? One of my previous episodes was with Roy Rivera and he doesn't do any physician marketing. The one thing he stresses is that with every discharged patient, he sits them down and says, "Did you like your therapy? Did you meet your goals? Will you write a Google review for us?" He gives them the link card and then follows up a few days later with an email that says, “Here's the link to Google. Would you please rate us and write a review?" Do you do something like that as well to improve your reviews online?

We started a couple of years ago where we said, "Let's take this seriously." We did an intensive 60-day campaign to get a bunch of Google reviews done. It was a face-to-face process where we were intentional about doing it. It's not something we wanted to keep up because for us, it didn't quite gel for our PTs long-term. The way I feel about our PTs is these guys work hard and they are good at one of the most important jobs in the world. I want to be great at that. Enjoy yourself. I don't want to load them up with an ongoing Google responsibility. We use bot ware and there are a few of these companies out there now where patients are sent emails asking them to do reviews. That's an automated fashion and that works well. We may only get one review a week per clinic or something, but that's all you need. I'm not an SEO master, but it does seem that as long as you're getting consistent reviews, it doesn't need to be a bunch. Get a bunch to start with because you don't want to see that there are 30 people or something that like you. As long as you're continuously updating that, that's what matters.

If you can get some ongoing consistent up-to-date ones, you don't want to see a review that's from a few years ago. You want to see something that's happened in the last month. That can always be positive. It sounds like you're also cultivating some of your past patients via email. Is that right?

As part of our online process, we do an email campaign to all our past patients we have emails for every month. It's not a one-off email. It's normally in a funnel mindset. It might be saying, "This is the first exercise we usually give for shoulder pain. This might help you if you have shoulder pain." You want to see okay. You don't want to be harassing people with emails that don't apply to them. You only want to re-email people that opened that email. For those people that opened that email, then you can send the follow-up email. It might be an article or it might be a web resource that you've developed or something else. Maybe after the next email, you give them a chance to opt-in for a free consultation or an operation. It's funnel-wise.

Are you using something like Infusionsoft to do that for you or another program to help you do that so it's automated?

I use two email software. We worked with Infusionsoft initially. It was complex. We work with Campaign Monitor and Drip, two different email platforms that work for us.

That works for you. Is that something that you're on top of? Do you have someone that manages those campaigns?

PTO 76 | Direct To Consumer Marketing
Direct To Consumer Marketing: One of the nicer things about direct access and being successful in online marketing is that we can now refer to physicians so much better.

 

I'm on top of that. I enjoy the content. Building that content and I'm deferring a lot of the responses to other people to manage. I don't need to go through and I don't go through and respond to every email. They go to other people that can respond. I will send emails from our other PTs. All our clinic directors, I'll send an email to their past patient list from them so that when they read that patient response, it's going to that clinic director who can then answer questions and so on.

Anything else you want to share with us about some of your successful online marketing strategies?

A key is to think outside the box. Workshops have been great over the years and they've been effective and they remain effective. What we all should be striving for is if you've done workshops, you know who generally goes to those workshops. It's folks over 55. You might get a few younger folks in there, but generally it's the over 50, 55 group which is great. We want to serve them and they're our bread and butter. For most of us, most PTs reading, if someone offered them a workshop on any topic, they would probably never go out. Who has time? Nathan, you might have a couple of kids.

We've got a couple. I'm a little busy. 

If someone were to say, "Nathan, why don't you come to sit down for an hour and listen to something about investing?" you have to say, "Will you give me the first $100 to invest?" You're not going to go. How do we reach people that wouldn't go to our workshop? Think outside the box. Think about what would get their attention. One thing we did that was effective was we created a full risk assessment page online. You could go to this page and you could answer some questions and it would give you a lot of great information. There’s video work on there too that tells people how bad their fall risk is. We had ads on Facebook and Google the directed people to, "If you want to find out your fall risk, here it is."

The great thing about that is that the CDC and Medicare are behind us. They desperately want us to stop people from falling down and breaking their hips. You can feel good about that educational program where people are learning, "I'm at risk for this. I didn't realize that many people fall every year and when you break your hip, it’s that much chance that you won't make it for another year." It's striking for people. That's been effective for us in educating the community. Those folks that need it, they're coming to the clinic to get their balance right again. They don't have time to come in there and sit around an hour for a workshop one evening, but they do have time to go through some emails, some texts, some phone calls, and then they're like, "I need you guys. Let's do some therapy."

It's a good exercise to go through before you start any of these campaigns is to think about who's your target audience. What do they need to hear? What are they thinking? What are some of their fears? What do they want to do? How is this inhibiting themself? If you have a good idea of what that avatar looks like, then it helps you write the content that's directed to them and it's going to get their attention. 

It's certainly helped to have true patients for a few years. It'd be tough for someone doing this. We know those marketing groups out there that aren't in this therapy space but they're trying to sell you stuff. If they don't know patients at this intimate level that we know them, it’s hard for those guys to know what they want to hear.

If people wanted to pick your brain and maybe see what you're doing on your end, is there any way they can get in contact with you? Would you share your information?

I'd love to chat with folks. What we all need as PT owners are lots of other great PT owners being successful. That's what we need most because if that happens, then people know they need to seek out good physical therapy as opposed to the other specialists. I'd love to answer questions and help and guide people for sure. I love doing that. My email is probably the best. It's Matt@StarPTClinics.com.

Are you willing to help people on this journey towards online marketing?

Absolutely, Nathan. I chatted with one lady in North Carolina and gave her some direction of where she could go. I enjoy doing that. We're going to be working with a small group of PT owners and taking on some of their online marketing responsibilities for them and building out some campaigns. The other thing is not only is the content time-consuming to develop but managing the funnel. Responding to the replies, the emails, the text, the phone calls can be pretty involved. Most PTs haven't got time for that. We'd like to handle that for them as well.

That could be huge. It could be a good resource because if you're not a content creator and you don't want to do it, you don't have the time to develop the funnels. Most importantly, follow through on the metrics and see what's working, what's not working in any particular area. You’ve got enough stuff on your plate already as a PT owner and I'm assuming my audience would love to have someone help them with that.

I'd love to. It's a blast. We enjoy it. If we can help, that's a win.

Thank you so much for your time, Matt. I appreciate it.

You're welcome, Nathan. It's been a pleasure. It was nice chatting with you.

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About Matt Slimming, PT

PTO 76 | Direct To Consumer MarketingMatt has had extensive training and specializes in treating the spine, lower extremity and vestibular rehabilitation. He is certified in the Fishbain DOT-RFC Functional Capacity Battery, Golf Fitness, and Essentials of Musculoskeletal Imaging.

He completed Barefoot Running, Surgical conditions for the athlete, Tennis Rehab, Running Rehab, BEST Exercise Program for Osteoporosis Prevention, Rehabilitation for the Postsurgical Orthopedic Patient, Modules 1 and 2, Physical Therapies in Sport and Exercise, Modules 1, 2 and 3, Muscle Energy Techniques, Evaluation Manual Correction and Treatment of the Sacroiliac Joint, and Direct Access Medical Screening.

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PTO 75 | Private Practice Owner Coach

 

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

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Listen to the podcast here:

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

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

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

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

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

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

Did you always have aspirations of having your own clinic?

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

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

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

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

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

You eventually went to Atlanta and decided to do that?

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

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

How long ago was that?

That was the end of 2017.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We're all in the same boat.

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

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

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

 

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

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

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

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

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

You're a step ahead already.

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

You're going to have to expand.

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

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

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

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

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

That was hard. 

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

It is a detriment to the profession as well.

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

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

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

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

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

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

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

I'm looking forward to it. 

Thanks.

Take care.

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About Avi Zinn

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

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

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PTO 74 | Internal Marketing Programs

 

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

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Listen to the podcast here:

Successful Internal Marketing Programs With Mike Bills, PT

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

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

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

Thank you for having me. I'm excited.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

Train, drill, and practice. Click To Tweet

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

It is 11%.

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

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

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

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

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

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

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

 

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

Who's creating all that content?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

You're welcome. Thank you.

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About Mike Bills, PT

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

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

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PTO 72 | Billing In-House Or Outsourcing

 

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

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

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

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

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

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

No problem. Thank you for having me.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

The numbers don't lie. 

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

Not so much.

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

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

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

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

That can be difficult.

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

What was his name?

His name is Matt Slimming.

We'll have to remember him.

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

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

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

Thank you very much.

Important Links:

About Amy Sparks

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

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

 

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PTO 64 | Developing A Winning Team

 

Developing a winning team is crucial for an organization or company to reach its goals. Craig Phifer, PT, the CEO of Rehabilitation and Performance Institute of Evansville, IN has put systems, rubrics, and filters in place to REALLY hone in on the successful characteristics and traits of the top performers in his company. Plus, his company's focus has been on providing his team the autonomy and support to pursue their individual dreams. Putting these two focuses together has allowed RPI to create a culture of aligned individuals looking to significantly affect their community - and they've done that! They've grown to five clinics in three years and will continue to grow, considering the incredible team members they are developing to take more responsibilities. Plenty of insight in this episode! Get your pen and paper handy.

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Listen to the podcast here:

Keys To Developing A Winning Team with Craig Phifer, PT

I've got Craig Phifer out of Evansville, Indiana, CEO of Rehabilitation & Performance Institute. I was going to talk to Craig about an article that he wrote in Impact Magazine entitled Assembling Your Winning Team. My initial thoughts, and I was mistaken, that he was developing a leadership team, but he was talking about assembling a winning team and a culture throughout the company. The reason why I'm excited to bring him onto the show is because the things that they've done to filter, hire and train have developed and refined their culture to create one autonomy for their providers, of stability and purpose for every hire that's in their practice. They've grown to five clinics over the last few years. I’m excited to bring in some of his successful actions and share those things with you. Craig does an awesome job in explaining things. There's a lot of stuff that was like, “That would have been great if we did that. I hope everyone's reading to this.” There are plenty of things that you can do within your own clinics to take advantage of what Craig shares with us.

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I've got Craig Phifer, Owner and CEO of Rehabilitation & Performance Institute out of Evansville, Indiana. Thanks for coming on, Craig. I appreciate it.

Thanks for having me, Nathan. I appreciate it.

I recognize Craig's article in Impact Magazine about assessing a winning team and I think that's such a vital part of the growth of any clinic, especially if you're looking into multiple clinics, if you're looking to free yourself from some of the day-to-day tasks as an owner, so you can become that leader. It helps to start creating a culture and an environment that's not solely dependent upon you. First of all, I want to get into your story, Craig. Why don't you tell us a little bit about your professional path and what got you to where you are?

Years ago, we started RPI. Prior to that, I had been running an office for a large orthopedic practice, transitioned into doing it on our own and started with the idea of things weren't heading down a great path for PTs and clinicians. We were starting to sense a lot of those classmates you would talk to who’s the smartest people in the room. They're great and you think, “That person’s going to go out and they're going to be awesome. They're going to crush it.” You talk to them about two years in and they're starting to talk about like, “I'm not sure I want to be a PT anymore. I want to get out of this. I'm trying to find something else. I'm trying to do something different or something nonclinical.” It’s like, “You're so much smarter than I am. You are the person at PT school who I thought was going to be out there doing amazing things. I'd be reading all about you now. Here we are and the profession is beating you down two years in.”

When we started RPI, the idea was how do we put clinicians in the best possible position to succeed? How do we strip away all the things that don't matter, that we spend time and money and attention on? Can we take those away and focus on the stuff that matters, that puts clinicians in a great position to deliver great results for their patients? We're still searching for that every day. We're still trying to make changes and tweaks. I think we've done a lot right. We've also found out we've done a lot wrong, but a few years in and we have five offices in the region and it's going well.

Congratulations, that’s awesome. It sounds like you've developed a model where you're the owner and CEO, but you also have some partners in some of the other practices.

It's hard to change a community in a meaningful way when you're not living in it and when you're not involved. Click To Tweet

Our company has nine owners in total. What we've done is you have all these people who made a personal investment in the company without making a financial investment in it. We got to a point where we thought you can't expect as an owner for somebody to put the same amount of blood, sweat and tears into it as you have. When you have these people who do, you need to reward them with something like that. I don't think it necessarily has to be ownership, but we thought that was the right choice in our company was to say, “You can buy into ownership. You're doing such amazing things. This company is successful because of you. We're better when you're a part of the decision-making process.”

Do these people tend to then be the clinic directors at the individual clinics or have some management responsibilities on top of their physical therapy work?

Almost everybody in our company has some management responsibility outside of physical therapy work. Some of those owners do manage an office. Some of them don't. Some of them help refine our clinical processes and they play a role in that. We say we need 30 hours of clinical care to make the company go. That's what pays our salaries and the bills. What we want to do is condense that 30 hours to where you have some other chunks of time you can use to do what it is that want to do, what you've told us you love outside of just treating patients. We have somebody, she’s wonderful and she gets our company mission well. She gets our vision and we got big enough to where it's like, “I can't manage the HR stuff on my own. We need somebody who's doing that.” She took that role and has done awesome in it, much better than I was doing.

After you get to where you're excelling and succeeding in your relationships and the care you're providing patients, we think that takes about two years for most. We've had people who got to that point. One of them was less than a year and we were able to say, “You're doing great. You're doing phenomenally well. When you're ready to take on something else, we've got things that we think you'd be great at. We need you to think about what you'd want to do outside of treating patients. We can start to make some of that happen.”

How do you assess when they've come to connect with patients, they've been able to develop relationships and see great results personally between them and the patients and professionally with their results that they're providing?

We have two main things that we measure for every clinician in the company. We measure for every office and for the company as a whole. Definitively, I can tell you our most successful offices on every measure, and this includes financially, boil down to these two pieces. The first one is therapeutic alliance with patients because that's such a great predictor of people dropping off or not. People dropping off in physical therapy is such a massive problem that doesn't get nearly the attention it deserves.

When you say dropping off, are you talking about the 10% that complete their plan of care in our industry?

PTO 64 | Developing A Winning Team
Developing A Winning Team: Think about what you want to do outside of treating patients and start to make some of that happen.

 

Yes, that is a pretty big number. That's our primary measurement. Our second one is we have offices that are about 80% direct access. How many of your patients said, “I don't just want to get physical therapy. I want Eric to be my physical therapist. That's the person who's going to help me. I trust them before they come in.” When you have created relationships to a point where your patients trust you before they ever come in the door, that’s powerful for being able to help them completing care. It helps us from a cycle of we don't need that many new patients because they're not dropping off as much. We don't have to spend very much on marketing. We don’t have to spend very much in a lot of areas because our patients are staying. If somebody is successful and a lot of their patients, request them not just coming in for physical therapy, but request you and then our measurements of therapeutic alliance, if you're succeeding in those two areas, I can tell you everything else was going to be good.

This isn't the topic, but I love how you guys are doing things. I want to learn a little bit more. The situation in which maybe they ask for Eric before even coming into therapy, is this because a prior patient of Eric's has referred a friend or family member to Eric?

Yes, that's one of the big ones. The other one is community involvement on an individual level. We want to put people in a position where they're living, working, playing in the community they're in or from. If somebody has to commute an hour to work, it's hard for them to be actively involved in that community. Not that they can't do a great job, but it's hard to change that community in a meaningful way when you're also not living in it and when you're not involved. I would say about half of that comes from community involvement. It's got to be something you genuinely enjoy being involved in. We don't want anybody to go out and say, “I'm going to join this running group even though I hate running because I know a lot of runners get hurt and need PT.” That's the wrong reason to be there and it doesn't work. It needs to be something you love doing anyway. A lot of people are being part of their church. For some people, it’s being active in running groups. For some people, it's helping coach youth sports.

Your therapists seemingly from the get-go, as soon as they come on, there’s an expectation that they're going to do some outside involvement or promotion. I wouldn't call it marketing, but they're going to be involved in the community such that they can find ways in which they can help.

Part of our hiring process is that we are looking for people who have already shown and have already demonstrated that they like being active in the community and they like doing things like that. It doesn't feel like work to them. It's something they would do no matter what they were doing for our profession. We think that those are the people who change the health of communities, people who are out there working in it and interacting in that community.

That's part of your interview process. It’s like, “What kind of community activity are you in? What kind of groups are you involved with?” That's one of your main criteria for joining you.

When we talk about defining who is successful in your organization, the people who are the most successful for us, to a person or all people who enjoy being out there in the community. They don't even have to be extroverts necessarily. We have a lot of introverted people who have things they like to do in the community or in their particular group. There's no right or wrong way to do it. It’s like, “We don't have anybody involved in soccer in this community. I need you to like soccer and go out there and get involved.” It only works if it's something people want to do anyway.

We're all pretty overstimulated and it's created this need for flexibility. Click To Tweet

Those introverted people, they're not necessarily introverted when they're in a comfortable environment. When they're part of that group, maybe they're introverted but they like CrossFit. There's their tie to a community. There's a group that they can be a part of and benefit from. I had an interview with Sturdy McKee out of San Francisco. One of their criteria for bringing people on was they would ask people if they participated in team sports anytime during their lifetime. If you said no to that, they wouldn't hire you on. I bring that up because there are some things that are outside of the box and you alluded to this in your article in Impact Magazine about assembling a winning team. There are some things that you're looking for. There are traits, characteristics, even personality types that you want to bring on and create a winning team and sustain the proper culture in your company. You get down to, “We're hiring for this person, a physical therapist. They're going to be actively involved in their community. If they're not actively involved in their community, that might be a red flag. We might not necessarily hire them.” Would you go that far?

Yes. Some of the mistakes we've made through the process is one, initially, we asked people about their desire be involved. Everybody can give you a good answer in an interview. PTs are smart people who are great test-takers. They've exhibited that throughout the doctoral training they have. People can give you a good answer to a question. We've had to start to look at less about the answers to the questions that we ask but more, “What have you done? What are you currently doing? What are the questions you're asking us?” That tells us more about what you're interested in and what you're trying to achieve, then your answers to the questions we ask you.

Say the community involvement, do you take that down to even some of your administrative personnel whether the front desk person or an aid? Do you take it that far?

Everybody, yes. It's an important part for every role. There are certain things that we look at are traits where somebody might be successful as a PT, versus what they'd be successful as a clinic director or clinic manager are different. The same thing for somebody who is working in a front-office role. Some of those traits are different, but there's a lot of overlap and community involvement is some of the overlap.

I can see where community involvement in your situation has bred a culture and an environment within your companies from what it seems. When you get down to job descriptions, then there are different traits that you're looking for. In your article, you talked about rubric development. There are certain things are looking for, but there are also certain things that might come up as red flags. You mentioned yellow flag as well that you want to make sure you steer away from. Is that something that you've developed over time or did you sit down ahead of time and say, “These are the people that are super successful. What do they have that makes them successful?” How did you develop a rubric like that for the different positions in the company?

One of my favorite books that I stole this from is Work Rules! by Laszlo Bock. He used to be the head of people development at Google. It’s a fantastic book where he says, “You've got to put your top people under a microscope.” Your culture is almost like a living, breathing thing and it's changing as the people in your organization grow and develop. If your culture stays stagnant, that's probably not great. Your culture is changing, developing a little bit. Who was succeeding a year ago are the same people still succeeding now. Study those people. What we did is we put people through five whys, “Why is Eric so successful? Eric's patients seem to like him, but why do Eric's patients seem to like him?” You keep going down the road until you find the traits of that person and compare that to three, four or five other people who are doing a phenomenal job for you. You've got a pretty good handle on those. These are the things that make somebody successful in our culture and also change with us as we grow and develop. They're the ones who have kept up through the process.

Are these typically people that have been with you a long time or are you seeing some of these most predictive people even in your recent hires?

PTO 64 | Developing A Winning Team
Work Rules!: Insights from Inside Google That Will Transform How You Live and Lead

We had some in very recent hires that have come on and picked it up better than I ever could have imagined.

Do you attribute that to your interview process? Do you attribute it to looking for those certain traits?

I think it helps. I'd be lying if I didn't say that we nail it every time and that luck wasn't a part of it too. We've built a culture where in our area we've become well-known of if you can get a job there, that's where you want to be. It's going to work outpatient or orthopedics. We put ourselves in a good position of having a lot of people to choose from. That's been incredibly helpful.

I'm sure the people you've brought on that have been successful and enjoy being there will attract people. They've got friends either from PT school or in the area and they're like, “I can get you on.” These are like people and they're going to have similar traits. There's a huge advantage to that.

Some of our best hires have come from somebody saying like, “I know we don't have an opening right now and we're not exactly trying to hire somebody. I've got somebody who I think is going to be phenomenal.” Everybody at our team is cognizant of what we're looking for and what somebody needs to be successful through us. There are people that said, “That's a good friend of mine. However, I don't think they're a great fit here.” Somebody who said, “We weren't that close in PT school, but I know them and I think they're going to do awesome here. They're going to be great. I think we're going to be great friends even though I don't know them that well now.”

Having your employees be part of that filtered process is amazing and powerful.

It made the recruiting so much better. From the first time we were trying to hire somebody, we had to go through five, six, seven different channels to get one or two applicants. It was hard. We got to thinking like, “If it's going to be this hard to hire a PT every time, what are we doing here?” As we started to get our name out a little bit more and our own people started to feel like, “We’re onto something here. This is going great.” I don't want my friends to work here. You should leave where you're at and move here and come work. That's been phenomenal for us.

20% of your time should be spent on something that you love. Click To Tweet

That's a great position to be in. Are you doing any recruiting work in some of those surrounding PT schools as well?

We have people who are quite involved in local PT schools, a lot of lectures and a lot of students. We value the clinical learning process. Anytime some of the local PT schools want to send us somebody, the answer is yes. We just got to figure out where to best put them so that everybody is successful.

Have you ever hired a PT without necessarily having an opening because you knew they were the right fit?

I've got a few people who crushed it for us. We knew them beforehand. They did great in the interview. We knew they were somebody who are going to be able to drive some of their own patient care volume. That came from us saying, “We know that fewer than 10% of people who need PT get it.” There’s a market out there that if we're able to reach the people that we can help, our PTs have the ability to drive their own schedule. When we find somebody who we think can do that, we'll hire them no matter what.

A lot of people will consider that a leap of faith. You talk about this in your article about giving them some autonomy. I like how you used the word autonomy and not necessarily responsibility. You haven't said that they have a responsibility to generate their own patients. You more talked about how they're in control of their own schedule. I'm sure you have some expectations, but it doesn't seem like it's coming from top-down. It seems like somehow you developed the culture that allows them to be internally driven.

That was the exact thought process when we started. The big things that make something go are autonomy, mastery and purpose. If we can drive those things and put people in a system where we have autonomy, I think part of autonomy is flexibility. Can we give people some flexibility and schedules and how we get things done? If we just tell them, “This is what we're going for, this is what we need,” PTs are hardworking people. It's hard to get into PT school in the first place. It's hard to finish PT school. Once you've finished PT school, it's hard to pass your board exam. We're picking from a group of people who are smart, driven and motivated. We need to give them the platform to let all those qualities shine. That's what we're attempting to do.

From an owner's perspective, from my past experience, when you talk about a scenario like you're in where a lot of your PTs drive their own patients and patient load, a lot of PTs that I come across almost seems like that's the company's responsibility to market the doctors, talk to the people and get out in the community. If you want me to treat patients, I'll do that all day long. What I'm finding out is that you've filtered those types of people out.

That type of person no doubt exists. We've hired that person before and it's not that they haven't been okay. They haven't excelled in our system. I understand anybody who wants their career to go like that. Not everybody wants to work in our system where you're probably only going to be successful unless you want to do some of those things. Filtering some of those people out through the interview process, but also as we bring somebody on, we want to help them find the reason they got into this in the first place. PT is a profession. We're incredibly autonomous people probably to a fault. Most people want to help others when you show them that this is your best route. If you want to help people, this is absolutely the best way to do it. You can’t only have them in your life for 45 minutes twice a week or whatever it may be, depending on where you work and never see them again or never see anybody around them that you're going to make a change. You might be the best clinician ever, but you're still not going to make a change on bigger level.

You're promoting your physical therapists to make a difference outside of the clinic. It extends beyond the clinic, extends out into the community. I love that you brought up the fact that we only address 10% of the people that actually need us that have musculoskeletal injuries because a lot of times we think there's so much competition, but when we're talking about competition, it's for the 10%, it’s 90% out there. We could be such smaller fish in a bigger pond if we could reach that other 90%. That's a huge difference. You talked about getting rid of some of the things that lead to the two-year-old PT to be frustrated and looking for something else. Maybe I'm putting words in your mouth but it leads to burnout essentially. What are some of those things that you've pulled away from your therapist to help them be more engaged, involved and minimize possible burnout?

PTO 64 | Developing A Winning Team
Developing A Winning Team: PT is a profession. They’re incredibly autonomous people probably to a fault.

 

The first thing we wanted to address with our therapist is to put them in a situation where they were only having to treat with one person at a time. PT is realized when you're seeing two, three, four people at once, no one is getting the best of you. We're such a caring, altruistic profession people by nature that I don't think anybody can internally deal with that very well. They either need to shut their own professional life off from everything else if they're doing that because they have this internal feeling of like, “I know I could be doing better for them. My system doesn't allow me to.” Our first part was if we don't spend money on stuff that doesn't matter. We spend money on your relationship with that person and the things that allow you to develop a relationship with that person. We want to get people to where they feel like they're making a difference because they are. We give them that element of purpose.

The second thing is I think we're all pretty overstimulated and it's created this need for flexibility where there are times where we want to work, there are times where we want to get away from work. I will always say that if we have a job at our company that a working mother can't do, then we don't have a job that's two jobs. My wife's a PT. She's a professor in the local PT school. If she can't do a job within our company, I haven't provided the flexibility of somebody who's going to be great. That was our next focus of saying we need this many visits a week. We need 30 hours of patient care. You tell us how that works for your schedule. You tell us how to make that happen and you have a couple of patients in the morning cancel. That's okay. Your schedule is your schedule. I'm not treating those people. You are. If they can't make it in and you're going to come in an hour-and-a-half late because your first two patients scheduled and now you've got something else you needed to get an oil change, that's perfectly fine. We'll see you when you come in.

As a past owner, I can think about some of the issues with that because there has to be an expectation as far as productivity. You talked about that in your article about how you create measurements or statistics with your employees. Tell me a little bit about that and how you maintain productivity in your situation.

For us, we tell everybody before they ever start. It's the best question somebody who's interviewing for a job in PT should ask an employer is, “How do you measure if I’m successful?” Because oftentimes the answer just ends up being more when you don't know if you go into a place, “Am I doing well? Just see a few more patients, build a few more units and you'll be good.” We tell everybody before they come on, this is exactly what we're looking for from a productivity standpoint. We put that piece aside, “Here's how we find it best to get those things without running yourself into the ground because nobody needs that. That's not good for you, for us, for your patients. Here's how you get it that without reaching those burnout levels.” Once people figure out, “Here’s how I get those things. Here's how I do a good job. I find out I've got a lot more energy. I've got something else I want to take on.” Let's talk about your other goals. We have a professional development period, our pyramid for people where they're able to say, “Here's the ultimate goal that I want and here's a couple that are leading up to that.” We'll talk with everybody monthly about, “What are you doing to get toward that? What can we help you with? What kind of obstacles can we help you remove to make that happen?”

What are some of the statistics that you measure your providers by? Is it visits per week or some other statistic? You don't have to share numbers, but what are the KPIs you use?

We talked about the big two and if those are going, then I know pretty well everything else is probably going to be good. From a pure productivity measurement, it’s visits per month. It is the timeframe we look at. From that, we have a unit per visit. We have a range. It's going to be slightly different depending on your particular office. Those are the two things that are pure productivity. I think it's good for everybody to understand before they're going in that if you were working on a line and you needed to put out ten widgets in your shift to make ends meet, then you know, “I need to make ten widgets to make the ends meet.” For us, that's how we make money. That's how we continue this. That's how we help people, “Here's what we need financially to make it everything else go so we continue to help people.”

Where did you come up with the 30 hours per week of treating? Did you work backwards from what you need as far as revenues? How did you come up with that number?

Everybody tends to gravitate toward the person teaching them and leading them. Click To Tweet

We pulled it out of the 80/20 rule. We want 20% of your time to be spent on something that you love. We started saying, “Can we make that happen? What do we do to it to drive that?” Then we worked backwards, “If that's what we need, here's about how much we're going to make per visit in our area.” We knew that. “If we can generate that much revenue, here's the bucket we have to spend on.” Anything that goes outside of that, then we've got to start saying, “Here's what we don't need. Let's pull that out.” We're more of a destination place. We don't need to spend astronomical amounts on storefront and being the most visible location. Most of our patients drive past somewhere else that offers physical therapy to get to us. We’re very comfortable with that because it means we don't spend a lot of money on square footage. We spend a lot of money on the relationship with our patients.

I love how you guys have set up. This is something that you've probably developed over time is your interview process. You seem to have nailed down. It's pretty close to a solid, finished product. I've talked about this with other guests and consultants. Bringing up the productivity expectations at the very forefront is huge. Leaving that as something that's part of their training is wrong. They need to know exactly what they're getting into and you need to be upfront about what the expectations are. I think that goes a long way. I love how you talk about what is their professional path. Some of them might want to be lifelong clinicians and that's okay. You might have a position for that. There are some people who are like, “If I'm doing these ten years from now, I'm going to shoot myself.” You've offered an opportunity to show them that there is a path for development. I think that's huge as well because you then are aligning what they want with what you can provide and show them a path to do that. That gets a lot of buy-in into the culture.

We've developed a couple of people right out of our organization. Somebody might say like, “That stung you. They developed as an individual faster than you are as a company that they got this great opportunity somewhere else that you can provide them.” It's like, “I think that's awesome.” We're able to provide the kind of place where people can grow and develop. If you're developing yourself so fast, because we as a company, we have everybody. We're growing as a company. We're doing lots of new things and lots of exciting ventures coming up. If you're even outpacing us to where we can't provide you the opportunity, good for you. That's phenomenal. I'm glad that happened and I'd be happy to help you do whatever you want to do.

I loved reading your article about assessing a winning team. You developed a team, not just the leadership team. That's how I went into this, helping people recognize what it takes to develop a leadership team. You’re talking about a team from the bottom up. You're talking about developing a team and growing than you're leaders from the get-go, and you've provided a professional track for them to do that. There's some development in place. There are certain levels that you address on a month-to-month basis, which is very cool as well. You're having one-on-one meetings with them to do that. That's all amazing. When it gets to leadership, what are some of the things that you might have them do? Are there some tests that you take them through? What do they need to do in order to become a leader in your company?

We have been developing that path to different leadership. The qualities that we found internally people who become most successful in that role, one of the big ones is vulnerability. That person is able to share, “This is where I've failed doing that or this is something that I have trouble with.” It puts everybody at ease when you realize that this person I look up to and that I'm following are not perfect either. As far as qualities go, that's the quality that we've tried to develop culturally within our organization. We see our leaders have high levels of that.

You're that from an observational point of view, I'm assuming.

We’ve noticed that those are the people that almost attract others. They might be a staff physical therapist in their role and we might have three other staff physical therapist there. Everybody tends to gravitate toward that person teaching them and leading them. A lot of times it's the person who will sit there and they're talking after work about a patient they're struggling with and the person's like, “That's tough. I don't even know what's going on. There are so many directions you can go in. I'm stumped.” That person is the one we're finding that other people naturally start to follow.

PTO 64 | Developing A Winning Team
Developing A Winning Team: Don't spend a lot of money on square footage. Spend a lot of money on the relationship with your patients.

 

If they’re interested in leadership, do you tell them, “There are books that you should read,” or do you give them small tasks to see how well they handle management?

Both of those things. We have almost a progressive reading list of things. The first part of it is leading yourself. If you don't know you, you could argue that very few people actually know what they want, why they want it, how those things developed in their own life. If you can know you, that's where we want you to start. The book I love for that, that we recommend is The Subtle Art of Not Giving a F*ck by Mark Manson. I think it's a phenomenal book. The title scares people off because you're like, “I do want to care. I don't want to learn how not to care.” It's more about teaching you how not to care about things that don't matter and finding out what does. That’s our initial reading list book. We find that once people understand themselves well, it becomes so much easier to lead others.

You said a lot of people in your organization have some responsibility. Are you talking even down to the physical therapy aids if you have them or even the newest physical therapist? Did they have some responsibility?

For the most part, we don't put other things onto people for the first six months to a year. We have had people who jump into things right away and show a natural proclivity too like, “I enjoy doing that. I want to do it.” We're like, “You do your thing.” We want people their first couple of years to be about honing in clinical skills and working with their mentor through that process. Developing a system and developing their own pieces of it where they know when they're successful with a patient, when they're not successful with the patient, where they went wrong, what went right and focus on that element of expertise. As you get that, we want you to start taking on some other things.

It sounds like that you've systematized things that there's not a lot of subjective recognition of how well these people are progressing. You've got a system in place for the training and also for their assessment.

We've got it up about as objective as it can be. There are certain things that I don't feel can be fully objective measurements. It’s about as much though as it can be.

You can only go so far, but if you can define those traits of the successful people, what they're doing and how they're acting and list those things out, then it gives you a blueprint for how the next person's going to be. It can change. There can be some modifications here and there and not everybody's the same, but you have a general idea of what makes them successful and people can follow that. That makes things a lot easier, especially on the owners when it comes to training up the next person.

Once people understand themselves well, it becomes so much easier to lead others. Click To Tweet

We can say we've got a system around you that you don't have to think about all these little energy-draining elements throughout the day. Our job is to make sure that all that's done for you and that you can focus your attention on the task at hand, which for a lot of people is going to be that patient in front of you. If we can do that, we built a good system.

What's your meeting schedule like? Whether it's in the individual clinics, with your leadership team and with you and the owners. What is your meeting rhythm like?

We have quarterly ownership meetings and monthly leadership team meetings. Every clinic director meets with every person on his or her team once a month as well. We find that when it's too much more frequently than that, people get by meeting. If it goes too much longer than that, we have a lot of people who feel like they're being left out of the loop on what's going on because we have so many things that we're trying to develop and move forward.

The clinics themselves outside of the director and their team members, do they have typical staff meetings once a month as well?

Yes, we try to provide opportunities where we can get together as a group. Our clinics, their farthest apart are about two hours. We try to provide something at least quarterly, we’re doing something fun getting together, nothing to do with work where we can do something fun as a group and everybody can bring their kids. We found that's a helpful element for us too.

We found that same thing. They call them quarterly town halls. They got it out of Verne Harnish's book, Scaling Up. When they can get together, they'll talk a little bit about values or maybe focus on one value, have some activities and get-to-know-you games. It’s huge for the culture and maintaining that and even creating it. People get a lot of buy-in from situations like that.

It has been big. It's probably the thing that I would say we need to continue to get even better at is creating more of those opportunities, more different things that everybody wants to be a part of involved with. We don't want anybody to feel like, “Here's this Saturday morning where I have to go hang out with these people.” That's something that we provide for everybody generally who wants to be involved with.

PTO 64 | Developing A Winning Team
Developing A Winning Team: When meetings are too much more frequently than once a month, people get deaf by it. If it goes too much longer than that, a lot of people feel left out of the loop.

 

You want to invest in that because I'm sure you're seeing the impact of it, the ROI on that, culturally speaking is huge. Craig, thanks for your time. I appreciate you expanding a little bit on the article that you wrote in Impact Magazine, Assembling Your Winning Team. You are doing a lot of things great and it shows in your growth. It's impressive. Thanks for coming on.

Thank you for having me.

If people wanted to reach out to you, are you available on email or social media?

It’s @CraigPhifer on Twitter. That's a great place to reach me or CraigPhifer@Gmail.com.

Thanks for coming on. I appreciate it.

Thank you.

Important Links:

About Craig Phifer, PT

PTO 64 | Developing A Winning TeamCraig Phifer, PT, MHA is the owner/CEO of Rehabilitation & Performance Institute.

He is on the Editorial Board for Impact Magazine, and helps PTs start their own practice through craigphifer.com.

He can be reached at craigphifer@gmail.com and on Twitter @craigphifer.

 

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PTO 62 | Selling Your PT Business

 

Paul Martin has been dealing with mergers and acquisitions in physical therapy since the turn of the century, so he knows the market. However, things are different now than they were even five to eight years ago. Today, Paul shares what you need to know if you're looking to sell in this environment, and what you should know about the current industry even if you're not thinking of selling. As an independent owner, you should recognize what's going on in your local PT space - who is getting acquired, what acquiring companies are looking for, and where they might be going next. These are things that will keep you abreast of the industry and where you fit so you can make sound decisions. Even if you’re not looking to sell, consider some of the things discussed here so you are maximizing the value of your practice and be ready to sell at any given time. You're going to exit someday, so be prepared.

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Listen to the podcast here:

Looking To Sell? Five Things To Know About The Current M&A Market with Paul Martin, PT

On this episode, I get to talk to industry veteran, Paul Martin of Martin Healthcare Advisors. He has been around since the early ‘90s. He has been advising physical therapy companies since 2000 with Martin Healthcare Advisors. He's helped over thousands of clinics both grow and merge and be acquired or acquire in the physical therapy space. He's been around the block a number of times and now, he has five things he wants us to know about the current M&A market. Those five things are important to know because things are different now than they were several years ago. There are significantly more players, more acquirers in the market space and some of them coming in within 2018number of private equity groups on top of the ones that are privately held and large, but also those are their publicly held. 

Things are different. It's not all about EBITDA anymore. There's a lot to do with what's your growth strategy? What are your cultures like? How do you fit in their footprints because some of these are regional players and not national players? Do you add something to the space that they're trying to get into or increase a footprint or provide a niche service? Are you on a growth trajectory? All of these things are what they're looking for and provide greater value to them. There are things that you need to know in order to provide more value for them as well as provide more value for yourself. I'll continually beat the drum ever since I did the interview with John Dearing last year as part of the podcast about how to set yourself up to sell. Doing some of those things to improve the value of your clinic to sell are the same things that improve the value, the profitability and the power to improve your clinic currently. Doing some of those things improves the stability and freedom that you get to enjoy. 

These are things that are somewhat simple, fundamental, but also take some effort and if focused on increases the value of your clinic. Things such as making sure your legal paperwork is in order to make sure your financials are in order and easily accessible and easily readable. Know your statistics, especially your cardinal’s statistics. Make sure you're on a growth trajectory year over year. Do you have a leadership team in place so that you're not the sole decision-maker and not the sole influencer in the company so that if and when you do leave, things will continue to run well and continue to grow? 

What is your culture like? Do you have mission statement and values? Those things are important because if you're looking to sell, you want to make sure you sell to someone who has that same value system in place. It makes things so much easier when you do and it allows for greater growth even after the acquisition. There are a number of things to consider. Paul goes over the five most important things to understand in the current market. I’ll continually beat the drum on making sure that you have your company set up for sale at any time. It increases the value of your company and increases the power that you have independently. Let’s get to the interview and see what Paul has to share. 

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I’ve got Paul Martin of Martin Healthcare Advisors on with me for the interview. Paul has been around the block a number of times and is doing some great work now for the profession. First of all, Paul thanks for coming on. 

Thanks for having me, Nathan. 

If you don't mind, you've got a wealth of experience based on your time in the profession. Would you mind going back and sharing your story first of all and tell us about your professional path and what got you to where you are now? 

I am a physical therapist by background and I started a company a few months out of school back in 1989 that was called Physical Therapy and Sports Services. I and two partners grew that company. It started driving growth in 1993 when we had three clinics and from 93 to 96. We really accelerated that growth and we grew to 21 clinic locations. Subsequently, we sold that company to NovaCare in 1996. I spent three years with NovaCare and it was a great experience. I felt I got somewhat of a degree in corporate rehab. I learned a lot from the folks at NovaCare. I left NovaCare in 1999 and started this company, which is a company that provides growth and development consulting in the industry as well as merger and acquisition representation of companies that want to go into the market. 

PTO 62 | Selling Your PT Business
Selling Your PT Business: Remaining independent means you have to be consistently looking at good, solid growth opportunities within the market.

 

Who's your ideal client at this time? Who are you targeting? You might be helping those guys toward the end of their ownership phase. When you talked about growth and consulting, who are you targeting there? 

We work with companies of all sizesanywhere from a single location company. As we look at our client base, there seems to be a look in the eye of our customers of wanting to learn more about the business of physical therapy, wanting to grow their practices and seeing that in their markets that in order to remain independent, it's necessary for them to continue their growth. 

What are you seeing there when you say in order for it to be necessary to be independent? You’re recognizing that in order to stay independent, you need to have a larger footprint or you need to be at a certain size compared to the hospital networks or the physician-known physical therapy clinics and whatnot. 

Most markets, the large national companies in just about every market in the United States are coming into those markets, acquiring the larger practices are putting a lot of capital into growth with new clinics, new startup clinics. We really advocate if you want to remain independent, you need to be consistently looking at good solid growth opportunities within those markets. 

You’re not only helping people who are growing in that respect and trying to either open de novo or acquire other clinics, but you're also focused on helping those who are trying to exit their practices as well. That’s a little bit about what we're going to get into now, right? 

Absolutely. We have a whole division of our company that takes some advantage of this current market or have looked at it as a strategy to transition their company to a larger business in many different shapes and sizes. 

What are you seeing as far as the market? It seems like there was a pretty hot run there for the last five years. Do you see us on the downhill side of that or do you see it continuing in the expansion of mergers and acquisitions? 

Based on the capital markets, based on the continued ability for private equity to be able to borrow at very low interest rates, but as you look at our economy, etc., we do believe that this market may have hit its peak and every time we get there, we're seeing new private equity groups coming into the market. This is a very long haul for a market to stay as aggressive as fertile as this market has been in the rehab industry. How long will it continue? It’s very difficult to say, but for right now, there are great opportunities. 

Definitely and I think I learned that from one of my episodes last year from John DearingMaybe I'm going out on a limb, but some of it might depend on simply those interest rates as long as money is easy to borrow. Mergers and acquisitions might be prettyI wouldn't say hot thing, but it's been active. 

While the interest rates are definitely a driver, the other driver is private equity seeing this business as the rehab business as a good business that they see it as a fairly simple business. They look at it. They don't see that our reimbursement over the last ten years or so has seen that much change. I'm not saying it hasn't seen any change, but that much change. There haven't been any major changes to our market with any type of regulatory issues that have come up. The public companies, US PT, as well as Select Medical have fared very well in the public eyesIt brings attention to our industry and the private equity sector seems to be very much of a copycat industry. When one private equity group has success, it's not long after that another private equity group is going to follow that group trying to do the same strategy. We've seen that happen over and over again to the point where there are literally eighteen bonafide private equity groups backing fairly large rehabilitation companies in our current market. It's up from six or eight along with the public companies. It’s really moving fast. 

The private equity sector is a copycat industry. Click To Tweet

With so much private equity coming into the marketplace, how are things different? Maybe that leads into a little bit more of our topic. How is the market different for the physical therapists who are looking to sell now compared to several years ago? 

It leads exactly into what we wanted to talk about which you’re exactly right. It’s what we've come up with which are the five things you’ve got to know about the new rehab M&A market. It seems like we have a new market really on an annual basis. There are so many changes that the market continues to go through this evolution. The first thing you’ve got to know is that we're no longer in a market where you can simply sell when you and your business are ready. Historicallyit was back in the days of three or four acquires in the country, business owners would get their business in good shape. They would be ready personally and they would go out to one, maybe two or three of those companies and you could get a decent deal. You could sell your company on your terms at your timeframe. It’s no longer like that. With 25 plus companies, you’ve got eighteen private equity-backed companies. You have two publicly traded companies and at least five other fairly large scale private companies that are all vying for market share within these markets. They're all at such different stages that the market will dictate when you're able to get a good deal for your company, not simply your evolution. That's one of the things that has changed about this current market. 

Are you saying that if you're an independent clinic owner at this day and age, should you be ready to sell at any time? What would you recommend my readers do if their practice owners, especially if they're later on in their ownership and they're looking to phase out maybe in the next five to ten years? What would your recommendations be? 

It’s really important to, on a very routine basis, every few months or so to pop your head up and survey the market around you to seewho are the companies that have made acquisitions in your market? The companies that already made those acquisitions, what is their activity? Who is around your market that may be looking and would be the next likely kind of suspect to be coming into your market? To understand based on those companies and their evolution within the private equity investment of those companies the best time when you have what they need? You're going to get the best deal when you match what they need with something that you can bring. 

How does an independent practitioner, working in quite a bit treating patients or working on their business, where would they go to find those kinds of resources that would tell them who are the active players in my market and who's coming into the market? Because they'll acquire businesses but not necessarily change the names at times so it might hard for them to find that out? 

It’s important that you find someone that lives in this industry and understands, especially the larger companies they believe and somebody has told them that you need to use and find a large investment banking firm, may be out of New York City in order to properly sell your company. The problem is that those companies don't know who the buyers are in this market. These are all privately held companies. Even those backed by private equity are still privately held companies. They're not making public announcements, they're not being vocal as to where they're going next and what they're going to be doing next. You’ve got to find somebody who lives and breathes in this market and understands who they are. 

PTO 62 | Selling Your PT Business
Selling Your PT Business: It’s vital that you find someone to guide you who deeply understands the industry.

 

It's someone like you or maybe a local broker that's in this industry or people like that. It'd be hard I'd imagine as an independent guy to find out all that information. I can see where it's important. In my experience, my partner and I, had three or four offers over the course of a number of years that came to us from different directions. There are plenty of friends that I have that have clinics that have never been approached whatsoever. It seems like it's hit and miss as to who you know or not, what you know and that kind of stuff. It's important to be connected with guys like you that can guide you a little bit. 

We believe it's a big value. 

How should an owner establish or set up their practice to get maximum value? Maybe that leads into the next part a lot of times they'll talk about EBITDA and whatnot and how that drives the value of a clinic, profits, gross revenues or growth in general. What are some of the things that we should be looking out for to maximize our value? 

As we've outlined, I think the second thing that you need to know about this market is that the deal value drivers have changed. What I mean by that is in the past it was, everybody used and get five multiple. That's what everybody should be able to get and everything was about EBITDA. I'm not downplaying that EBITDA is not important. It still is important, but the biggest driver that we're seeing in this market is the competition for your business. Wcoined your EBITDA plus who wants to be in your market now? Who needs to grow in your market, who needs a platform in your market now, who's out there that would be the best fit? That's where you get what we would describe as the best deal. 

You're talking about maybe being aware of where the companies have a footprint in your geographical area and see if maybe you fit well into that footprint or you provide a niche service that could benefit a player in the area. 

Awell as being able to provide that potentially in some very unique ways to a number of those companies where you have a number of companies looking to get into your market for different reasons. You have attributes that may look solid and may look attractive to a number of companies then it's the competition for your company all in what we would call a synchronized competition all done confidentially. That's the process that gets and drives what we see as the best deals in the market.  

If you don’t mind, I'm going to use a personal example. When we sold our clinics and formed Empower PT, it provided a nice footprint for the private equity firm in the Phoenix Metropolitan Area. If you were a business looking to possibly sell in maybe Tucson or Northern Arizona or maybe even Southern California, that's where you might be a value add to a company that's looking to acquire businesses. 

Maybe an in-state business that's looking to go to a market that you serve in-state or potentially if you're large enoughother companies looking to come into a state and compete, you may be able to provide something unique to each of those companies based on their needs. 

A lot of people talk about establishing yourself and with your experience working with growth and consulting in M&A, how long does it take for them to get their business into a good position to get the maximum value out of their clinics? I'm of the opinion that it takes almost a year, maybe two years to ship things up to put yourself out in the market. What's your experience in that? 

The biggest driver that we're seeing in today's market is the competition for your business. Click To Tweet

Our experiences that depending upon where the business is in terms of its metricsin terms of whether it has a compliance program, in terms of where the EBITDA is and in terms of its ability to grow. As long as all of the things within the company are ready in this current market to do it right and to go out to multiple companies, the process that seems to be most effective is put everyone on the same starting line at the same time and drive a process that requires them to stay within a timeframe. You're going to quickly eliminate those who aren't interested or may have their focus on something else at that point in time and then driving that. We've seen it in a range of four to six months, which is much better for the business for much better, for the business owner than going through a process of working with this company for a couple of months, seeing what you can get then walking away from them possibly and go into another one. We see a lot of this franticness of, I’ve got to talk to everybody,” and by the time you go through all that, it's a year later and what have you accomplished? When the business is ready, what seems to be most effective is to put everybody in the same starting line at the same time. 

If I have a friend who has two and going on to three clinics and he's looking to sell in about five to seven years but he doesn't have policies and procedures in place. He doesn't have an employee handbook. He's been working full-time most of the time and now starting to pull out of treating full-time. How long would it take a guy like that to get ready to even go on the market? 

We see a lot of companies like that, as being a practice owner. When you get to that, it's no man's land. That two to three clinics to maybe five to seven clinics and have you set up the management structure, have you set up the systems and the processes for the company to continue on profitably? To do all of that and to set all of that up again, depending upon the stage of the business owner. A lot of motivation to want to focus on and work on their businessthat could be a one to two-year process to get all the things in order to be a business that has the strong ability to grow. 

What are acquiring companies looking for? You talked about something that maybe adds to the value of the company, whether it's in the geographical space or whatnot trying to enter a certain market. What are some other things they're looking for when they're looking to acquire companies? 

Different from our previous timeframes and previous markets, the third thing you must know about the new M&A rehab market is that right now it's very attractive to a buyer if you are what we term as growing through the deal. What we mean by that is historically it was all right, I'm going to pull back and try to do everything I can to maximize my EBITDA. Maybe pare down a little bit and certainly not do any new startup clinics and not start anything that would require any investment. Don't make any changes and just pull back. 

In this current market that will not make you attractive to the acquirers in this market because they want companies that can grow. They want companies that have shown the ability to grow. There are a number of different ways in order to look at some of those attributes and look at some of the expense you may have incurred to start a new clinic or an investment that you've made. Ways to structure that within deal companies that have shown the ability to grow and appear to an acquirer as we are growing our company and we are managing our company as though we're never going to sell it. That's attractive in this market. 

That can be tough because when you're growing like that, it can take a significant amount of cash to open up a new clinic or to acquire a clinic and then that's going to negatively impact your financials, which the acquiring companies are going to be looking at. At least through my experience, they can understand that cash is currently going towards opening a new clinic, but it should look at as a positive when it comes to the acquisition. 

It needs to be a balance and that balance needs to make good business and strategy sense. If you're throwing every bit of capital you have and at a new startup clinic and the startup clinic takes twelve months to go positive cashflow, those are not good business decisions. You need to continue to have balance between growth and margins and you're correct, the acquirers understand that growth takes the capitalThere's going to be added expense on your P&L because of that. There are usually many ways to adjust that as well as look at the structure to reward someone for the fact that they're growing. We say this all the time, we need to be the train that's leaving the station and who's going to jump on. 

PTO 62 | Selling Your PT Business
Selling Your PT Business: It's important to identify your culture for your company to continue to thrive.

 

They’re going to look at your EBITDA still, but they're also looking for growth. They're looking for what kind of value you can add to their marketplace. Are there are some other things that they're looking for when they're assessing your companies? 

Companies that are able to drive for their markets at or above the benchmark level of cash per visit are very attractive to a buyer because it means that you're managing efficiently and your staff is productive. That's real attractive versus them looking at this and saying, “We're going to have to teach that staff how to bill correctly and how to charge for everything they're doing.” These companies are moving at such a rapid pace that they're not looking for turnarounds. Many times a business owner will say, “Won’t the acquirer see that has great upside opportunity for them?” They will, but you may never get to the finish line of the deal. They’re in a neighborhood and you’re a broken-down house that needs all the fixes and there are three shiny new houses in your same neighborhood and you don't want to be left behind. 

They’re not necessarily at this stage looking for something that they can fix up and they're going to have to take some time and invest money and effort into. They want to acquire something that adds to the bottom line and move on to get the next acquisition. 

We’ve coined it as speed dating. They are moving quickly and they aren't going to spend a lot of time on a deal that looks like a turnaround they’re going to focus their efforts on, because there are a lot of companies that have put their hands up that are in the pipelines of these acquires. 

Where do other things come into play, especially as a clinic owner? How important is it for the independent clinic owner to have a mission, purpose and values all established and maybe having a particular culture of some kind? Do acquiring companies look at that? 

It’s important and we see it as even more important for the seller. In the current market, many of the companies are offering a structure of a partnership. If I'm going to go out and find the right partner as you just described, culture is important. It's important to identify with what is your culture and what's the culture then that you're looking for your company to continue to thrive and not every acquirer brings that. They don't all have the same cultures. They all have different and unique cultures. When we look at and talk to companies that are looking to potentially sell their business, we say, “You may not want to hear this, but it's not all about the price. Culture is first and foremost as what we see in this market that becomes most important to a seller. They're going to be in there for a long time and they're going to be working along with the acquiring company for a number of years. It’s important, especially if they're going to be in a partnership and they have equity and they can benefit from growing that business. 

From personal experience, there was an opportunity for us to interview seven to eight different acquiring companies as we were on the market. I'm talking about this second hand because my partner was on a lot of these interviews while I was up here in Alaska. He said it was obvious as they sat at the table that things just didn't align. It didn't feel right. It seemed their focus was someplace else, whereas our focus was over here. I think the initial take is that they're all the same. These are all the same companies that are trying to get into the physical therapy market. They probably have the same values, where that's not the case at all. They have completely different values, different objectives and different mission statements so as the seller, it's highly important that you have all that established and that you know what your ideal acquirer looks like. You should probably have a good idea of who you're going to marry before you marry them that leads to a happier relationship down the road. 

There is no question, your perception of that as you were going through this is dead on. We do this a lot so we see it over and over again. When you can sit for three days, the owners of the business and we together met with seven different companies all within a matter of three days and asking a lot of the very same questions to each of them. You're exactly right. They came out with at least four of those companies. There's no way they said that those companies would meet what they were looking for in terms of culture. The other three have different attributes and that's where we start looking at what we see ithe next element that drives the best deal, which is structure. This is number four things that you got to know about this market, which is there are so many different structures in the market now. There have been five private equity groups that have gotten into this market within the last nine months. They all can come in and keep doing the same thing as their competitors. They have to bring something different and unique. 

What we're seeing is they're bringing some unique structures on how the equity in the future will be paid to the seller and where that equity is placed. Structure is right behind culture we say this, “You name the price, I'll name the structure and I'm going to win every time.” In this market, that's true. We line it up in a matrix and look at simply price. Many times when you look at the real value of everything that's going into the deal, it flip-flops in terms of where you're getting the greatest value based on the structure. 

The people who are selling need to know that there are different ways that they can get paid out. Is that what you're saying? That the structure of the deal could be no cash? It could be a percentage now and a percentage later? What are the expectations of your job after the fact? Is that what you're talking about when you talk about structure? 

Yes. There was partnership structureUS PT was on the forefront of the partnership structure and they've utilized a partnership structure certainly with their acquisitions as well. That partnership structure has been sliced and diced in multiple different ways from newer companies, the new private equity that has come in, in order for those companies to try and stand out. A big piece of it is not that you're not getting a good portion of what you're receiving for your business upfront, but how can we structure that back end to make it attractive and to make it secure? That’s where it can be fortunately and unfortunately. Fortunately for folks like us and unfortunately for sellers in the industry, it has become very complicated. What’s always a good structure for the acquirer may not be the best structure for the seller and it's that work on the backside of thatTypically, it's with the equity and where the equity is and how you get it out. That is important in this market. 

What’s the fifth thing we must know? 

We call the fifth thing of market separation. What we mean by that is in this current marketyou have multiple acquires and they're all at different stages of their growth. They're all seeking markets regionally based on the evolution of their growth. For example, a company that has been backed by either new private equity or our first round of private equity. Once they get their structure in place, they're going to be looking to grow. At year three, four, they may be looking to wind down somewhat in order to prepare for the next private equity investment. Companies that become what we call recapped, a new private equity group comes in and takes out a smaller private equity group. All of a sudden, you have a geographical need in which as opposed to staying somewhat regionally, we see those companies and we call it leapfrogging. 

A company that's primarily New Jersey, New York, all of a sudden they're doing an acquisition in Illinois, Michigan and Louisiana. This is what we call market separation which we no longer have one big market with just a couple acquirers. There are segments of markets across the United States and they're all different based on who the acquirers that are looking to get in and what stage in their evolution are they in and it changes. With these new private equity groups, a lot of them are West Coast-based. I think you're going to see a lot of platform acquisitions on the West Coast. We were a part of one of those. We’re seeing some East Coast acquirers and it's slowed down now gearing back up with some higher-level management, etc. They're going to look to jump back into the acquisition game. It causes what we call this market separation which is, it's so interesting and cool when you can look at it from the United States view. If you're in a market, you're in Pennsylvania, to see all of that, it is difficult. It has made it somewhat complicated. 

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As a seller, the important takeaway is to recognize where these acquirers are coming from. Do they have a national footprint or are they a more regional player? At what stage are they in? Are they three years into this acquiring phase or are they brand new? Is that what you're saying? 

Exactly, and are they looking for platforms? Are they looking for add-on acquisitions? Are they looking for niche practices within certain markets? You coined it pretty much dead on. 

There are lot of takeaways. Those are valuable information especially if they're considering to sell anytime soon. If they want to get an idea of what the market looks like, it's important to have all these factors in mind. Are there any recommendations that you make to a guy whos like, “I'm not in the market to sell. I'm relatively new in my practice and I could be here for another twenty years and maybe grow with a couple of clinics? 

You want to make sure that as you grow your business and if you're on the very frontend of your career, the reason private equity is investing in this business is that it's a good business to be in. We work with companies across the country that are looking to remain independent in their markets. The keys to that are knowing and understanding what's going on around you, but looking to find and to capitalize on market niches that are focused on things that you serve those people better. You double down on those specific market niches that you can serve because you will typically be able to serve them better than the large companies. Being and living in your own market and in many cases, having grown up in that market. Going out and finding those market segments that you can serve better is I think one of the first things that we talk to companies about as they're looking to evolve within a market looking to grow. 

It comes down to solid blocking and tackling. You are making sure that you're establishing operations and financial budgets. You are making sure that you're looking to grow your staff in a way. You're looking to evolve leaders in your company and continuing to provide the best service of any company in your market or state and active in your community. Don’t let anybody out there tell you that just because such and such company did an acquisition in your market that you're not going to be able to survive anymore and you have to sell to one of these companies. No, that is not the case at all. 

I had guy John Dearing on and wtalked about what to do to prepare to sell. The big takeaway for me was that even if you're not looking to sell, being ready at any time, having your house in order per se, to be ready to sell at any time typically means you're profiting the most. You're running at peak performance anyways. Acting as if you were on the market can definitely lead to benefits as you said, having a leadership team where you're not the sole focus of management and leadership for your company. Having set policies and procedures, having clean books have an operating budget. Have your compliance manuals together and your policy and procedure manuals together because they're going to look at all those things. Even if you weren't selling, having all of those things in place makes you a more profitable company and it improves performance. 

We've seen companies have great success who early in the game have said, “I wonder what the value of my company is now in this market.” What that does is it makes it very clear internally what some of those value drivers are and can help guide decision making in the future. If you're looking to provide value so that you can pass this along to your children that may go into physical therapy or you're looking at some point in time to transition out of your company. We’re all going to leave our companies at some point in time. Understanding what that value is and what the internal value drivers are I think is also a good step to take early on because it will also uncover some of the things that you just said. 

Do you have that compliance program in place? Are your financials in a structure that's going to be easily assessed by acquirer? Are your leases in a structure? Do you own buildings and how are you dealing with your building ownership? Is that ownership in your company or did you put that separate? Are you running fitness programs and other programs that also under a structure, should be looked at and done differently? I think it's important early on to prepare your company for that value look later on and whether that's passed down to your staff, your children or going out to a third party. It is important. 

PTO 62 | Selling Your PT Business
Selling Your PT Business: Even if you're not looking to sell, being ready at any time means you're profiting the most.

 

I love that you tied it back to value. If we use them what increases our company's value as a decision filter, then that would lead our decisions to improve our value and improve our profitability. 

Profitability is important, but as you look across the company, it comes down to profitability and risks. What you want to do is to look to minimize risk by having a very diverse referral base, by having a payer base that's fairly diverse versus one singular payer base, a payer that may be federally funded, that could be changed overnight. As we look at our staff and the arrangements that we make with our staff, as we look at our management structure, everything we do, you want to look to build solidly which reduces risk. 

Is there anything else you want to share with us, Paul? 

This has been great and I appreciate you having me on. I hope this has been valuable to your audience. As I said before we got started, you're doing a great thing for our industry and I appreciate that. I'm glad I found you and I'm glad I was able to get on and talk to everybody. 

Thanks for your time. If people wanted to reach out to you, how would they do that? 

You can send me an email. That’s a pretty long one, but it goes right to our name. It's PMartin@MartinHealthcareAdvisors.com and certainly jump on our website to see what we do and how we do it, which is www.MartinHealthcareAdvisors.com. 

You're going to be presenting some of this information in the future whether that's at PPS or other conferences. 

We are. We did mergers and acquisitions conference that is called Better Strategies for Higher Valuations. We did that in Chicago back in early June and we're looking to do another one right before the Private Practice Section Conference on October 29th in Orlando. We'll be sending out invites for that and it's a nice way to start the conference. We'll do a five-hour teaching a training session and then that would be followed by dinner and it's a great time to network with other business owners across the country. 

If people were looking to go to that meeting the day before PPS, do they go to your website or do they reach out to you individually? How do they do that? 

We’re going to be sending invites out. Certainly send me an email, tell me you're interested and we will make 100% sure you get an invite and you're able to attend. 

Thanks for offering that and being a resource in that regard againThanks for your time. It's been great getting to know a little bit more about the M&A market. 

Nathan, it’s great talking to you. 

Thank you. 

 

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About Paul Martin, PT

PTO 62 | Selling Your PT BusinessPaul Martin’s personal experience makes him an expert on growing a PT company and selling it to a larger corporation. Early in his career, he grew his three-clinic rehab company in Moorestown, NJ to 21 clinics in only three years before personally negotiating the sale of the company to NovaCare in 1996.In 2000 he founded Martin Healthcare Advisors, a consulting and M&A Advisory firm dedicated to the outpatient Physical Therapy industry. Over the years, MHA has helped more than 500 business owners grow and prosper with their proprietary approach to strategic growth and succession planning.

As CEO of MHA, Paul has advised many of the most successful owners in our industry and his M&A team has led more outpatient rehab transactions during the last four years than any company in the country. He is a nationally recognized expert on the state of our industry and where it’s headed.

No one is better qualified to speak about what it’s like to sell to and work as a partner with private equity-backed companies than Paul Martin.

Paul holds a master's degree in Physical Therapy from Hahnemann University, as well as the prestigious “Certified Business Intermediary” (CBI) and “M&A Master Intermediary” (M&AMI) designations from the International Business Brokers Association (IBBA).

 

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