Over the past three months, Dr. Avi Zinn, PT, the owner of Druid Hills Physical Therapy, has made some big moves. He’s hired a new PT, signed on for another year of consulting, and switched his coach. He also continued to refine his processes with a new Prompt EMR and a new billing company. Thus, he has continued to grow his practice and has not had to step back into treating or be physically present in his clinic for a full day since March. Much of his hard work to establish systems and work on his business for the past couple of years is paying off for him, basically setting him to be a top-ranked PT in Atlanta, Georgia. Listen in as he shares these improvements with Nathan Shields.
This is Reality Episode 4 with Avi Zinn. We've followed Avi here in 2019. We followed you because you are a newer owner. We first got in touch because you were looking for some consulting help. If you want to hear about his story and whatnot, you can go back to the first episode. You decided to go with a consulting company. You've been with them since 2019. You have seen great growth in yourself as an owner and also in your clinic. We want to come up to speed.
In the last episode, we talked about how you got through COVID and how you're coming out. You’re optimistic about how things were going in general. Atlanta had opened up from lockdowns. You were projecting to continue to grow and bring on another PT. I’m excited for you in that regard. Bring us up to speed. What's been happening? We can talk about some of the trials that you might've had and some successes you've had as an owner over this period of time?
A lot of stuff has been going on since the last time. The biggest thing I listened back to our previous episode and I was talking about hiring on a new PT. The majority of what I was focusing on around that time was trying to figure out when the right time was to bring the new PT on because it was during COVID. It was hard to decide when things were going to feel like we're back to normal and clearly, we're not back to normal. We decided to go ahead and make the decision. Finding the right person is always challenging. It took a while, but I was able to find the right fit and we were able to get her started in the middle of September 2020.
Let’s talk about a few of the details if you don't mind. You were trying to figure out when was the “right time” to bring them on. What were some of the numbers you were looking at? What were some of the thoughts that were going through your head to make you decide to finally do it?
As a coach, you would not necessarily think I went in the perfect way. I didn't fully look at all my numbers to see that we were at a good utilization percentage or this and that. I got a sense by looking at the schedule and feeling that we were full. The world started opening up, we were getting more people wanting to come in, so it felt like we were busy and we need to hire on.
I assume you were seeing a jump up to a different level of new patient numbers or a consistent high total visit numbers.
It’s more total visits and new patients have always been about the same and that's also an indication of needing a new PT. When you get new patients but you're not getting more total visits. It’s because the PTs are discharging or too early. Some patients are falling off because we're too busy trying to get the new people when we can be focusing on the ones we have.
You got a sense that with the new number of new patients that you had, you weren't being as efficient as you could and getting them in for the 2 to 3 times per week or giving them a level of attention to the patients. Sometimes patients don't feel comfortable when the clinic is completely full. There is no table to do your exercises or they have to wait for that. You lose a little bit of patient engagement. You got some of those senses.
It was a few of those. Because of COVID, we've spaced out our clinics. We only do one patient at a time and there's not a space issue with that, but the therapist schedules were getting full. The patient engagement was more like we were letting people drop off and not having room for people and retaining them.
What were your concerns financially about bringing on someone? That's always an issue when I'm talking to newer owners. It’s like, “I've got to bring on this salary and the benefits for this PT. How is that going to impact me?” Had you worked that out or were you feeling uncomfortable?
I was feeling comfortable basing it on what it seemed like the influx of new patients and we were getting full. There were concerns with any time bringing on someone new. You’ve got to fill their schedule, spend a month or two trying to fill them up and you're still paying them. Luckily, I was able to find someone who agreed to start at part-time for the first month and then at the end of the first month, we transitioned her to full-time. What happened was even after the 1st or 2nd week, I had already asked her to increase her hours because we had enough patients. She was interested and she was happy to increase her hours.
That’s one of the benefits considering the situation that our industry is in. There are a number of PTs that are looking. I don't think that was the case in 2019. I don't know how many PTs would have been okay with starting part-time and then ramping up as they go. There’s an opportunity now for owners to bring on people slowly to build up their caseload that wasn't quite there a few years ago.
It allowed me to choose someone who I felt was a good candidate because there are a lot more people out there looking for jobs. I was able to find someone. I knew I had a little time so I didn't hire because I needed to fill a spot right away. We did get a little busy waiting to bring that person on, but I knew that I wanted to find the right person. That was what a lot of the work I was doing with the coaches. I've got my original coaching group, the Lighthouse Leaders, which is what we've been talking about most of the episodes.
Additionally, we talked about in the last episode where I hired Will Humphreys’ billing team. He also does coaching with me as well. I've got two coaches. I’ve got the coaching group and Will. A lot of what we've been focusing on is the mission, purpose, vision and values. Bringing on this new PT, I was able to make sure that she was aligned with our purpose and our vision. Making sure that she was the right fit for our team and not hiring someone because I need someone to be a PT in the clinic.
Was that a different process for you than what you've used in the past?
It was. Will helped me write some of the ads. He’s good. What did we write in the ad was about joining a team that is committed to values and purpose. Do you want to be a part of a team? Phrasing it that way. It gets better candidates because they are attracted to those specific things. I hadn't done it that way in the past.
Did you find that you got better candidates and people that were more engaged?
What’s interesting is that in March 2020, I was about to hire someone on. It didn't end up happening because of COVID and everything. Even with that candidate, she seemed like a good candidate. I was about to hire her, but it was something different when we spoke about the vision, purpose, future, growth and goals whether or not the other one wasn't the right person or not. It's hard to say it didn't happen anyways but this time, it felt different.
As you went through the hiring process, could you tell the candidates that weren't aligned or not engaged when you talked about values and whatnot? Did it help the filter system a little bit?
It made sense why I was doing that. There was one guy who clearly needed a job, which is fine. I don't blame him but all he was focusing on was specifics of like, “I want to work and I want to get paid.” Not anything more than that. That’s not what you want to say in your interview. Even though I was prompting him to talk about some of these things, he didn't align with or didn't buy into it.
If people are uncomfortable in that position when you talk about values, if their body language changes or they pay some lip service to it but you see something different in their job shadow, that tells a lot. When you put them up against the values, hold them to it and have them verbalize things related to your values, then it's almost like they self-select because they can't use the words if they're not aligned with the values. It comes across junky. You can always tell they're not comfortable. That helps a lot when you're going through that hiring phase being clear about those values and having those discussions.
You get a sense that they're authentic, sincere and it's someone that will be a good fit for your team because you can tell that they want to be a part of a team.
Not to spend too much time on this section, but it's awesome that you went through that experience. The part-time part of it is cool as well that she was coming on part-time for a couple of weeks. If it didn't work out over a 2 to 3-week period, you got some support but you're not fully committed so you have an easy out if they're not living up to what you expected.
For the reason of allowing me to ramp up with a lot less pressure.
Congratulations on the hire. Did you simply post something on Indeed and work through that?You can sense that someone is going to be a good fit for your team because you can tell that they really want to be in it. Click To Tweet
You’ve got the benefit of being in Atlanta, but you also have the benefit right now of so many PTs looking for work compared to past years. I'm sure you had so many to choose from.
The PT I hired moved from Houston. She's making a change. She and her sister wanted to both move to Atlanta.
There are a lot of PTs out there doing that.
People are moving from what's going on. You hear about a mass exodus from New York and people moving out of there. People are changing their lifestyles now because of what's going on.
I've heard about it with a client in Cheyenne. I've heard about it with some friends in Ketchikan, Alaska. People are uprooting from Chicago, New York, New Jersey, you name it, to give themselves an opportunity to reset so it's a good time to find those people.
With her moving from Houston, it was super helpful to have Will and his team as our billing company because not only has it been great having them as the billing company. The first main reason is I'm not doing the billing anymore. They do a great job. They have all their systems for keeping track of the billing, claims, deposits, EOB and all the stuff that they should be doing. They also do verification and credentialing. Since she came from out-of-state and she had only worked in a hospital system, her credentialing and all that stuff was way more robust. It was a bigger process to have to completely get her credentialed with Medicare and then all the other insurances. It was a lot of work that I’m glad that I did not have to do.
It's so beneficial to have someone do all that credentialing stuff for you because if you fill out the form wrong or check the wrong box then it can delay that credentialing process so much longer. You'd rather pay somebody to deal with those headaches. Tell us a little bit about also the consulting. You’re still with the same consulting company. You signed up again after being with them, but you're changing individual coaches. Talk to us a little bit about that.
I signed up for group membership or whatever you call it to be part of the consulting group. The year came up and it was time to decide how to move forward. The group has a new lead coach that is not a PT. He’s got a much different background. He’s a CPA and has a lot of experience with business consulting but not specifically in the PT arena. It was appealing to me to get a different perspective from someone outside of the PT realm to see what it could be like.
There's an opportunity there to get a different perspective and not work with someone who might be simply accepting of your reasonings, your thought processes and you haven't worked with him yet. Going forward, he's able to challenge you a little bit on some of those fixed ideas that you have.
It could be. The coach I had in 2019 was great, valuable and we got a lot accomplished. Having this new one to challenge me is exactly what I am looking for. To challenge me, dive into some of the financials and look at our numbers a little differently. In the first year of coaching, I had a lot to focus on other things whereas all the numbers are important. There was a lot of focus on our systems and a lot of things that were not so data-driven. This could be a cool switch with the new one.
That’s not uncommon. Will and I had at least 4 or 5 different coaches over the course of the number of years that we worked together especially if you delve into it a little bit. The CEOs that are out there that have coaches, they'll change coaches every few years to get a different voice and a different perspective. They also have strengths in different areas that you can build off of. Not to say that they're necessarily improving in the coach that they're using each time, but they're simply getting a different voice. Something that speaks to the owners or the CEO’s weaknesses a little bit more. I can see the benefit of that.
I can relate to that in two instances with the previous coach. Chris and Will in two separate occasions both talked about mission and purpose. Even though we're talking about the same thing, the way Will talks about it versus the way Chris talks about it is different. You disattach onto the language that they use differently and relate it to an experience or a construct that you have in your head. It allows you to think and approach it differently. It could be as simple as that. Hearing the same thing but hearing it differently.
As long as people are getting some coaching, that's my greatest concern. I've had coaches that were PTs and most of my coaches were not PTs or in the industry. There are people that have reached out to me to get some input and advice and some of them work with PTs and some of them don't. That’s fine, as long as you're getting some support, guidance and business training, stuff that we didn't get in physical therapy school.
As long as you're simply getting it, that's the first step and then moving on from there to make sure you have the proper systems in place. You're working on the right things at that stage in your business. We’ll have to keep track with you on how the new coach goes going forward. Tell us a little bit about what you've been working on outside of the hiring process. You've got the coach. You switched over to billing with Will as of last time we spoke. It sounds like things are going well in that regard and the other things that you've been working on.
Outside of hiring on the new PT, the billing company and we switched over to EMR so we’re still working with Prompt and they're getting better. They're developing their software and they're coming up with cool things. Every update, they have cool new features. One of the big pushes that we've been doing since Corona is social media presence. We had a little extra time but we didn't have a social media presence.
We’re posting more on Facebook, Instagram, creating blogs, video content and sending out MailChimp newsletter. One thing that we did was have the PTs make videos of introducing themselves talking about their philosophies to be put on the website and use as promotional stuff. To also send out to people so when they sign up for an appointment, schedule their first visit, it includes a video or a link to their webpage and say, “Meet your PT.” They can meet them before even getting into the clinic.
That was an idea that Jerry Durham talks about in some of his podcasts. I didn't exactly come up with that on myself. Including it in the email to introduce before people coming in. Along that same lines of social media is something that we've been talking a lot about in the coaching group, the Lighthouse Leaders, is relationship marketing. It's not the same thing as social media but in a way, a lot of our referrals have been from Google Ads and we do a lot of paid advertising.
I haven't focused so much on making relationships with people in the community. Not just doctors but also trainers, massage therapists, athletic trainers, running groups, or yoga instructor, whatever. I put that in the same category as our social media because we're reaching out to people and we're trying to be connected with more people in our community. We’re trying to widen our audience, try to figure out who our target audience is. We're a generalist orthopedic outpatient clinic. It's hard to say who our target audience is. That’s also one of the things that we have been working on. It’s the social media and trying to reach out to our community a lot more.
How often are you posting social media content? How often are you sending out newsletters via MailChimp?
We’re doing monthly newsletters. We’re posting only once a week. We should be doing more. We’re getting it off the ground. We’re trying to broaden our audience and try to figure out how to get more people to either like our page or follow us so that we can reach out to more people when we post stuff. I don't know too much about the social media stuff as far as using it for not personal stuff but as a business, how to get out there and reach your audience. We're trying to do it and see what happens.
I did a podcast with Angie McGilvrey. She's a master at it. They had a hurricane in Florida, which shut them down and it gave them an opportunity to say, “How do we want to reset our business?” Coming from someone who was not on Facebook at all, no social media presence or whatsoever decided to focus on a certain target audience and do more consistent social media posting, engagement and that stuff. They started like you. Once a week, they'd post something to a particular audience that they wanted to attract. A few years later, they've got a part-time videographer that comes in and they're spending a few hours each week. Three of them are doing different social media things. They’re posting 1 to 2 items a day. It starts where you're at. Putting someone in charge of that so it’s not you all the time and then focusing on, “Who are we speaking to? What do we want to say?”
The interesting thing is, and I don't know if you've seen this as well, but as I talked to my clients, they say, “Sometimes I post stuff on how to do certain exercises, muscles they need to be concerned about, and activities they need to avoid. I'll post something about a dog and the level of engagement goes up to 200%.” Sometimes, it's not always about them wanting to know what you know and you espousing all of your wisdom. Sometimes, it's about staying engaged and posting a picture of a nice sunset once in a while.
We haven't tried it yet but we will.
The cool thing about social media is you throw stuff out there, see what sticks, see what starts connecting, and simply start doing more of that because you find out quickly who's engaged and who's not.With the right systems and processes already in place, you don’t have to figure everything out every single time. Click To Tweet
You can see if there are 20 likes or 100 likes and go from there.
Have you had any HR hiccups that you've had to deal with? Not that you have to get into details but that things seem to be running smoothly for you.
Things have been smooth. No real issues or HR stuff. We've done HR stuff as far as developing a better employee handbook and some of the SOPs. In regards to the SOPs, our front desk has been with us since 2019. She got accepted to OT school, which she's most likely starting her program in January 2021. Before COVID, one of my PTs were transitioning to the clinical director. We put that on hold, but we're still talking about it and doing some of that stuff. Not officially but me, the front desk and the PT have been trying to develop a strong, solid SOP for the front desk so when we do get someone to fill her position, our systems are going to be much more developed and more efficient.
It should be seamless if we can hire in time that we can have her come in and even sit with the front desk for a few weeks before she leaves, that would be even better. We're working on that type of HR stuff but nothing like disciplinary things like, “Thank God, my team is great.” Part of it is luck and following the advice of the coaches and all this stuff. It’s working on your team, setting up everything in a way, meeting with your team, and making sure that everything is running smoothly and not being a micromanaging boss but also letting the team run the place and all the stuff.
The smart thing that you've done since you started was to recognize that you needed to spend time writing up systems and how things were done. That’s a grind and you're still working that at higher levels but now is when it starts bearing fruit. As you said, the team can run things and you don't have to micromanage. This is where you're working through that hiring process with your coach and Will, and establishing your mission, vision, values. It's the same filtration system for those candidates at the front desk as it was for the PT. You can have the same conversations, you can get into a flow of how that interview process goes, and also gain some experience in being able to quickly weed out those that won't be a good fit.
This is all working in your favor. The fact that you were working on SOPs for a long time. Your systems are getting into place. You've got someone who's at the front desk who thankfully gave you plenty of time, and notice as to knowing when she's going to take off so that you can start preparing well ahead of time. If the next person can come in and shadow your person to be successful and you have two people there working at the front desk for a short period or as long as you like, you're going to be set up well in that transition and hardly see a drop-off.
I hope it works as smoothly as you said. That would be great.
It all goes back to the work that you started doing a couple of years ago in putting together your systems and processes. It’s starting to bear fruit. I'm assuming where you're at, are you treating it all now? What does your weekly schedule look like?
I haven't treated since COVID, since March 15th, 2020 or whatever. I've been out of treating and I've been out billing since April or May 2020 or whatever. It’s been great because it has allowed me to focus on all these things and get some of these systems in place. Before that, I was always working on them here and there, but I've had time to sit down, write them up, get things going, get feedback from the team. Even get their advice on how we should do things and get things set in stone so we can use them efficiently.
You've been an owner for a few years. It took me 12 or 13 years to get to where you are to finally step aside and work on my business, so congratulations on that. What are the next steps for you, Avi? You've been through the process considering the mission-vision values. Part of the vision portion is setting up some goals, longer-term or even shorter-term. What are some of the things you're looking forward to in the next year or two?
I've still got plenty of work to do on the systems and everything. What I do acknowledge is that even in the year of having the coaching, I'm still not dialed into all my numbers. That's also one of the hopes of this other coach, he's got a CPA background and he might have a better sense of financials and stuff. I want to focus more on our numbers, be more data-driven. It goes back to the SOPs, but it goes almost to some of the stuff we were talking about in the last episode as far as leadership team. I've been in the process of implementing where the team reports their stats to me or to the clinic director and then the clinic director reports it to me so that we're all taking responsibility for our own numbers.
Looking at the numbers and being able to project and grow from those. I do have numbers and look at them, it’s just I don't have a strong grasp on them. Looking at the numbers of September and October 2020, October was our biggest month ever, which has 100 more visits than last month or at least. We hired our new PT. You would hope that at some point, but her schedule filled up quickly which was cool. In addition to it being the biggest month, our utilization was good for her first month.
It was at 75% utilization too. That’s a big accomplishment and that goes back to having all these systems in place so we’re not losing our patients. We’re aware of their plan of cares, cancellations, and making sure that the front desk sets them up for success by setting up their expectations before they're coming in and dialing in on all those things. Moving forward, now that those systems are at least in place, they could be refined and improved. It allows me to start looking at the numbers, projecting, and using that for some continued growth.
How many providers do you have at this time?
We've got three providers.
You’re starting to get into that phase where you start developing a leadership team. You’ve already started that process by pointing out who your next clinic director is. Considering what that leadership training process looks like in your clinic and start developing those leaders to do exactly what you said to start looking at statistics, numbers, working off of the numbers as to what to do going forward, and also tracking those numbers to see if they're meeting your goals and expectations. Developing a leadership team, getting a handle on the numbers are great things to focus on in a little bit for you as a leader. Are you considering further expansion in the course of 2021?
Yes, but it all depends on the pandemic thing. It’s hard because we have a space for more people if we didn't have to distance. In our clinic, we rearranged it so we could fit three PTs comfortably. They're all in separate areas of the clinic. That’s how we want to do it. I'm sure there are clinics that are not as distant and we can squeeze another one in, but that's how we feel comfortable with our clinics. As far as expanding, we could get another provider and fill the other hours. We're open from 7:00 to 7:00 or something like that.
For me, it's hard to make any real plans for that until some of this stuff calms down. I can see that if all of these systems continued to function and not only function how they are now but even better and improve, that growth will only be a matter of having the space, hiring the people, and getting the patients as far as growth goes big. I can't imagine it's that simple but if we have all these systems in place which we're developing, I can see how it's going to be easier each time we grow because there's going to be a process for everything that comes up and it's not going to be like, “I'm going to have to deal with everything.” We don't have to figure it out every single time. There will already be a process and it will be smooth when something comes up.
Congratulations on the new hire. Congratulations on the successful EMR and billing transition. You've gone through some great stuff and coming out of the pandemic well. We spoke about the last time, to gain more patients for this new provider, you do a lot of work with Google Ads. I assume you simply increase your Google Ad spend, revamped a couple of things and you're continuing to grow.
I will say that we are seeing more and more referrals, not necessarily from more doctors, but internal return patients, word of mouth, so that’s been cool to see also. We are playing around with the ads, boosting the budget, and all that stuff, but we are noticing that the longer we've been around, the more reviews we have. People are starting to notice us and know that we're here. People are referring their friends and family. At some point, we won't have to rely on the paid advertising and we can get patients by word of mouth and by being a part of the community.
I don't know exactly what year of ownership that is, but there is a point where your return patients start making up a significant portion of your clientele. You still have to market and get fresh blood coming in. Once you focus on starting that internal referral program and pushing patients to refer family and friends who are injured or need some help, that can be a huge boom to your new patients. It takes a few years to build up that base level, but you're starting to engage with them as well with the newsletters and the social media postings. These are people that already know, like, and love you. It’s best to tap into that number of people which could be in the hundreds and thousands over time. Tap into them and it could bear fruit.
That’s the hope. That’s what we're doing with the social media. We're trying to engage with the newsletter, people that have been into our clinical before so they've all been here. We're trying to keep in touch with them, let them know what's going on, introducing them to the new PT. We've been also creating some eBooks which have been fun. Giving out links to the eBooks. Providing value to the community and not necessarily looking for anything in return. The goal isn’t to get people to make an appointment from that newsletter, which would be great, but it's more of keeping in touch with the community. Hopefully, that will keep us on their minds. If they know someone, they'll remember to tell them that they had a good experience with us and that could create another referral.
Congratulations on the growth thus far. You're doing great especially at ownership. You’re making progress and to be where you're at is enviable for a lot of owners. Congratulations, you're making steps in the right direction.
Thanks, Nathan. It's definitely fun.
Dr. Avi Zinn has practiced physical therapy in many settings prior to opening his own clinic in Atlanta: outpatient orthopedic clinics, hospitals, rehabilitation centers, and in people’s homes. He is an expert in treating all different types of pain and injury, and in developing treatment plans that bring people back to their most functional selves as quickly as possible. Avi’s main mission in opening Druid Hills PT is to utilize the experience he has gained in the field 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 the Toco Hills area.
There are many statistics that an owner COULD track, but which are more important than others? In this episode, Nathan Shields’ guest, Craig Ferreira of Survival Strategies, Inc., answers that question based on his greater than 35 years in the physical therapy industry. Not only does he share the key stats to track, but he has also developed software to track, graph, and project. The power of tracking stats is based on the objectivity of the data, which tells you exactly what needs to occur to improve the status of your company and achieve your goals. Every successful PT owner that Nathan has interviewed and met is tracking and acting based on the key statistics they regularly assess.
I've got a returning guest to Craig Ferreira. He is the CEO and Owner of Survival Strategies, which has been helping physical therapy owners for many years. He is also the CEO of Hands-On Diagnostics. I wanted to bring him on because not only does he have a wealth of information, experience and expertise in relation to helping PT owners. If you want to learn his story, you can refer to our past episode. I want to talk a little bit because you've developed a software program to help us gather the most important statistics, especially those related to growth and where you can capture losses quickly that might be a detriment to your business. I'm trying to summarize it there, but first of all, thanks for coming on.
How are you?
I'm doing good. Let's jump into it. You've developed this program and I'm sure it's because of the decades in which you've worked with PT owners and its key statistics related to your business ownership. Talk to us a little bit about the statistics that are involved and some of the key components to it. In my conversation with Will Humphreys, and I'm sure you would agree, one of the key aspects of being a successful PT owner is to lead by statistics to measure those stats and see which trends are happening over time and work off of those statistics to improve your business. I'm getting my head of myself, but that's the importance of it. Tell us a little bit about what you're seeing and why you decided to develop this.
First of all, this came from my years of experience working in clinics. I worked in about 200 clinics myself onsite as a consultant in the ‘80s and the ‘90s and before the computers. There was one of a few items that I realized that people didn't have and to this day, they still don't have, which is you can keep a statistic. Let's call it new patients. That's good, but how many of these do you need to pay your expenses and to make some profits? People sit down with Excel and this and that and you can figure it out, but my software does all that automatically. You can say, “I want 20% profits and I have this expense and so on.” The system I designed automatically creates what is that bottom line, which is an important thing to know.
The other side of the coin is people don't know what could they do? What's my potential production with my existing staff? I made the software do that too. You not only get what are we doing? You also get, what could we do, what do we get to do or what must we do? With those parameters, you can also educate your staff as to, “Do you see this graph we've got here? Here's a red line. We got to be above this all the time. We could do this. This is what we're doing.” The owner has to include in that red line though, reserves and profits. If they don't put that in, they're not running their business as we know. They're just running it to pay themselves and hope that they can make some profits.
I find that with a lot of the clients, the people that I talk to and I saw it in myself back in the day, but we simply run along. As long as the bank account shows us that we have some extra money, then we would assume that we were doing well because we had none of this financial and formal business training. One of the first things I have to get some of my coaching clients to do is say, “How many visits do you need to break even?” Sometimes they don't know or, “What's that dollar amount? What do you got to make every month to not only cover all your expenses but also to provide you a little bit to put away in reserves and that 10% minimum profit margin?”
What are those numbers? Not to have those numbers is simply flying blind. As I said, you're hoping and wishing that the money shows up. If it doesn't show up, then you're scrambling with your head cut off. It's better to not be in that position but to be working from a place of certainty. I love that you said you have to share that with your team. Not only is important for the owner to know that, but the team should know that. They need to know when they're producing well, when the clinic is going well, and when the clinic's not going well. They should know that so they can do something about it.
I remember I had a PT once. It was in Arizona in the middle summer and it's a slow season for us. I said, “I don't know if we'll hit 150 visits this week.” She stared at me like, “I don't know what that means.” She had no clue. This was an experienced PT and it was no fault of hers. It was all my fault. I thought, “I'm not teaching my team the importance of the members and when things are good and when things are bad.” That was a learning experience for me. I'm glad that you said that.
Most of the people that come aboard with you are not trained in economics so they don't understand it. The point is that whole subject by its own definition would indicate that you need to understand the business, what could it do and what does it have to do? What are the areas of loss that eventually ended up to you losing money? I can guarantee you that I can look at any clinic. I don’t care who's it is and show at least a 10% loss at the front desk and another 10% loss in the billing and collection area. I've never found one I couldn't do that with. It's easy to say that you need to know how many new patients come in to make your bottom line. What's even more important is, what are the sub-things you see that make that happen like?Click To Tweet
One statistic that you must track or referrals that don't arrive and some people just don't do it, the front desk doesn't do it, or they don't even know that anybody that contacts that clinic for any reason is a referral. That has to be the concept. There is a phone call, an email, fax, a friend, a family member like, “I heard about your services. I want to come in. The doctor sent me.” Consider that to be a self-referral. Do they get in the door? If you don't track referrals versus evals, you can't see that you're losing about $1,000 every time you don't get that patient in the door. Nationally, I think that's about the average these days. Your front desk needs to know that. That's a $1,000 loss.
I don't think they understand that when people call and say, “Where are you located? What are your hours? Do you take this insurance?” That's not what they're calling about. They’re simply fishing and those are potential referral sources. If your front desk isn't trained to be the salesman that they need to be, they're going to simply answer the question and hang up.
The clarification I'd make there, if it's a patient calling, that's not the referral source to follow, but that is a self-referral. Those things have to be tracked. It then comes in and now they start canceling. That's the other area of loss. What do they do? They don't get it made up. They don't control the schedule. They take excuses. That front desk has got to be trained and good at communication and skilled. One thing I found out is that people don't track dropouts. I asked, “Do you get dropouts?” They answered, “Yes.” I asked, “What is it?” A dropout is self discharged patients. That's the way to think about it. They don't track it by the therapist so you don't see whose patients are dropping out more than others and all that other stuff.
Here's something you can do. This is a suggestion that I have for the whole profession. At intake, you should have a form that says, “It's a medical necessity that at the time of completing your services here, we need to see you in person.” It has to be done in person. That is a procedure that will help at least with the front desk and the patient. When they say, “I don't want to come back, I feel better, it hurts too much,” or whatever they're saying, “I understand, Joe. Remember in the intake stuff, you got to come back in. We got to complete the paperwork,” or whatever you want to say, the reason is you get the patient back in.
I've said it a million times on the show. I share it with my clients, but we both know the average number of patients who complete their full plans of care in most outpatient physical therapy clinics across the country is something 15% or 20%. If that stat alone is measured and improved, that can do wonders for your revenues and your bottom line.
There is no doubt about it. That's another area of loss. Those statistics you see need to be tracked to point dropouts, cancellations and no shows. That's a whole other thing, which has to be tracked. In my software, I track all this by therapists and then it automatically makes it by the percentage of arrivals. It does it mathematically so you can see the percentage of arrivals of each therapist and the clinic as a whole. You can also do this in Excel.
It's important to track that by provider because your clinic on average could be doing well. If you don't track provider, it could be a situation where 3 out of the 4 providers are doing above expectations, then the one provider is below expectations, bringing the average down to where you want it to be. When you go by provider, you're able to have the one-on-one conversations that need to be had and people need to be held accountable. Otherwise, you're going based on feeling. It seems like their interactions are going well with the patients, with the other team members and they're seeing the right number of people. If you don't get down to by providers statistics in terms of their billing and their dropouts, then you get a feel for exactly how well they're doing in your clinic.
The other thing you want to keep advance schedule, “What's scheduled next week?” That’s an important statistic. If you've got the advanced schedule, you can see what's coming up and you can also go, “This person normally does 60 visits a week. Next week he only has scheduled 40, what happened here?” For therapists, it's evals. The other thing that happens is discharges go out of crazy. If you don't track the evals against the discharge, it gets to be nuts. The advance schedule, the percentage of arrivals, which is calculated by the no shows, the cancels, and the dropouts. You've got the average treatment charge, which we haven't talked about. That's a whole other area where you're losing money. There's a thing called percentage capacity.
This guy should be doing 100%. He did 60% this week. What did he do for the other 40% of the time? Those are the statistics. What I did with the software is I've made it so that each therapist, the clinics that have been using this, the staff gets to the point where they fill in their own numbers. They sit there and they fill in their own numbers and graphs are automatically generated. It also shows their bottom line and their individual bottom line of potential. Personally, how many of these do they have to do? It doesn't show them anything about finances unless the owner wants them to because the software has four access levels. It's done extremely fast. As a matter of fact, I timed it. If you gather the numbers and you put it in a spreadsheet and you press enter, each therapist takes about three minutes a week.
It's the gathering of the data that could be theoretically the “problem.” They don't have the data. They don't keep the data. They don't know where the data is. That's a whole of the situation. The last thing that I realized and created was a thing called profit. This is the thing that we will love. It was the profit projection sheet, where you can take your expenses and a few other parameters and you say, “I'm going to hire somebody.” I plugged them in. I plugged in your salary, your taxes and they're going to add X more visits per week. What does this do to how many more visits do I have to do? What kind of money can I make on that projected income?
Here's the other thing that I've never, ever seen to be untrue. I have done hundreds upon hundreds of these profit projection sheets with clinics random from all over the place. When people sit down and tell me that they are not making any money, and then I sit down and show them, “What are you talking about? Let's take a look at this. With your existing resources, you could be making an extra $200,000 a year.” They go, “What do you mean?” I was like, “You can be. The reason you're not, we need to find that out.” Normally, it’s that they didn’t get enough new patients. They don't know how to control that. That's a whole other thing. In some cases, they have enough new patients. In pediatrics, for instance, we're working a lot with pediatric practices. Most or all of them have waiting lists, but that's not where they lose their money. They lose their money from inefficiencies internally, scheduling, charging, billing, no planning and no goal setting.
The software is made to do that, but with all this said, that's all nice we can talk about this. The last thing, the break-even point and the viable practice, there's only one. It’s when that owner recognizes that they cannot be in the treatment room all the time. There's no leadership. There's nobody looking at the numbers. There's nobody even designing the numbers. What I try to do is make it for a business where other people could be involved in the stat tracking so it's not all on the owner, which helps the owner out.
I love the financial projection portion of your program. I talked to clients when they're talking about growth, bringing on another PT and adding that salary. They say, “I don't see how it's going to work.” I say, “This is where you need to get your CPA and your bookkeeper involved and start adding some of those numbers and projecting and seeing what new patients or total visits you'll have to hit in order to make the numbers you want to make.” If you can do it on your own, that takes a step out of the process because you and I both know that you're going to have to set up an appointment with the CPA. That's a month out and it's going to take an hour on top of the other stuff. It's going to cost you something to do that. If you can start plugging and playing some of those numbers, knowing your reimbursement rates, you're going to be able to create that financial outlook on your own, which can be super powerful.
The other part of it and I made it a little section. It's like a, what if, “I'm going to open up a new income source or I'm going to open up a new clinic.” “You can do a projected budget.” You don't need to go to your CPA. You can sit there and put the numbers in. I've already done that work. It's fun. It also tracks the referral sources to see who is referring, what their specialty is, what part of town they're in, and the demographics of the referrals. It creates pie charts, graphs and all that other stuff.
You've been doing this for many years. You've been preaching the importance of key statistics, tracking, graphing and watching them. What do you find in most clinics that happen to the owner and the clinic itself when they sit down and take the time to measure their statistics on a regular basis? What transformations do you typically see?
I believe and know that anyone has a high intelligence level. That's my own thing. What I have found is most people can make decisions and do something, but the step that's missing is the observation of enough information to make the decision. What you see when an owner starts to see, “This affects that and that affects this. This is the bottom line. That's my potential.” I've been listening to people tell me that they can't produce, but I go and look and see that they're not producing. It starts to get rid of all the confusion. They get unconfused. The confusion starts to become a way and now they have stable things to view and understand their business from. It calms them down. The stress level comes down.
It's emotional at that point and it's completely objective. I love that it's analogous to a dashboard because when you see the stats, they tell you what you need to do next. You don't have to sit there and think, “What's going on? Why aren't I doing this? Why aren't I profit? What's happening to all my new patients?” You look at the stats and it tells you the story. You simply have to follow those stats and take action.
I'm going to give you an example I am seeing with every clinic we've ever seen. When the new patients go crazy, the discharges all of a sudden, go crazy. The therapist starts discharging.Most people can make decisions and do something, but the step that's missing is the observation of enough information to make the decision. Click To Tweet
They get busy and they start discharging patients or letting them fall off or whatever.
We then go and interview them. We put in what we call a chart review. The owner, somebody sits down with the chart and says, “Can we take a look? I noticed you discharge Joe here at the end of four patients. There are a few of the discharges, what's happening?” “I got too many new ones.” “Did we establish the goals with this patient? How come? What are we doing here? Aren't we supposed to be treating and helping people achieve their goals? Did we discharge him because we're too busy? That's a management problem. You've got to let us know we need more therapists. Don't just start discharging the patients.” It happens all the time.
My point is this, if you don't objectively measure, Joe, has new patients on an uptrend and all of a sudden, the discharges are above the evals or they spike. What do you do? You go and look interview Joe. The way we found it is chart reviews because the therapist will agree that, “I could have done some more. I didn't have enough time.” “We've got to get that fixed not financially, but because we're not getting the patients what they need.”
Now, you have a patient that hasn't fulfilled their goals and they're going around town telling family and friends that the physical therapy doesn't do anything for you. They're not telling everybody that they only went to four visits and they expected miracles. They're saying that, “The physical therapist didn't work for me so I'm not going back.” That comes down to the responsibility of that particular provider, not getting full buy-in and engagement with the patient and following them through to the full plan of care.
A long-term client of mine, Paul Salkovskis mentioned to me many times he's been treating for as long as I've been consulting, “The most important aspect of the whole therapy thing is the first interview with that patient, where I bring them to an understanding. Not only am I their therapist, but our job as a team is we're going to go the whole later and I need your agreement to stick with me. We're going to make that happen.” That’s key.
On top of what you already said, it seems like the owners that look at their stats on a regular basis and act accordingly are simply in greater control. They're in a more powerful position to do what the clinic needs. If they're in the treatment room full-time, then they're not seeing, observing, and not taking the actions that are necessary. What can help those providers who are treating full-time is if they number one, take control of their schedule and set aside at least a half-day a week initially, to gather the data, measure the statistics, break it down by clinic and provider and then act accordingly. Start from there.
Over time, you'll team members start reporting their own data up to you and you'll see changes in their behaviors as they see the data for themselves because that's their scorecard. It shows how they're doing. They tend to start taking control of their own areas and that provides them a powerful base off of which they can work, improve, set goals, and show progress. Once it starts with the owner and works its way down to the team members individually reporting those statistics, that's when you can start gaining some traction.
We have some long-term clients who I can think of one, in particular, has about 50 staff. All her staff is in my program and they play games. They'll go, “How many did you do this week? You did that minimum visit? I'm going to beat you this week.” This fun and they also get rewarded.
If people wanted to find out where they can get your software program, how can they find it, whether it's online or in contacting you? How can we get in touch with you?
The easiest thing to do at this point is I'm going to give you my personal email. The reason I'm doing that is because of COVID. I'm all over the place. We do have an office still, but everybody's working from home, at least in my profession. It's CraigLuisF@yahoo.com. If you have an interest, shoot me an email. Somebody can shoot me an email and I will ensure that either my assistant or myself sets up a demo if you want to see what am I talking about here? That would be the easiest thing to do.
I'm excited to hear about the part of your software that projects things. I think that's missing with our PT owners because they go off of feel. They might see numbers in terms of new patients, the total visits, and their bank account and they're like, “It's time. Let's grow,” but they don't know exactly what it's going to take? How that's going to affect things? What the financial implications are going to be when they do expand, and what they can expect? Having this software available to them can provide them some opportunities to look forward appropriately and know exactly what to expect and what needs to be done in order to be profitable.
It gives them a great tool. It's a fast tool as well. It provides the data quite fast and then it makes it a lot more fun, frankly, because you can see what's going on.
If you got a numbers nerd or something like that in front of a spreadsheet, you start throwing numbers up there and see, “What does that do?” Can it also reverse if I want a 20% profit margin, will it tell me the number of new patients I would mean once you have all the data?
You can automatically change the percentage of profits to anything and they'll tell you the new patients, the visits, the charges you need after your write-offs in the account. It does everything like that so you could see it. It's not just a spreadsheet of numbers. It's in a graph. You can look at it and it's got color to it. It's got an aesthetic.
I love this stuff, especially for PT owners. More resources are coming available to us, but there needs to be more of this and you don't find it available in the EMR. I'm glad that you created something like this.
Thanks for your time, Craig. I appreciate it. Do you want to share anything else with the audience?
I hope and know that everyone is pushing through what we all have to push through the stuff that's been going on. It seems to be getting better. One thing I would like to communicate that I noticed, because of COVID, the communication level has greatly increased between people. What I'm hoping is that when it's done, you don't decrease the communication level. Keep it up there because that's, what's keeping everybody's hope factor. I call it alive and creating, and what are you doing? Who's helping who? If somebody is in trouble, they can talk to somebody.Because of COVID, the communication level has greatly increased between people. Click To Tweet
I agree because as we were going through the middle of it March, April and May 2020, there were more webinars, free consultations, and that stuff that I don't think that's necessarily fallen off. It's important. You stressed for owners to know that the consultants at Survival Strategies are more than able to do a free consult with you. I'm willing to do the same for people at Hands-On Diagnostics. If people are still trying to push through, the resources are still there. We haven't backed off of our willingness to work with you.
You might not hear from us as much because there's not as much coming through the pipes day-after-day from Medicare and everyone else. They're still available. They're still there to help. They want to help people through and the resources there, the communication on the owners has to continue as well. They need to maintain a high level of communication with our teams. They need to maintain a higher level of marketing and promotions that they did to the doctors back then. They make sure they keep it up and don't let it back off.
It should be doubled or tripled. We have many clients now in the training company that are doing better than they've ever done. The reason is that their communication level to their community has been quadrupled. That's an important factor. It's a pleasure. If you ever want anything again, I'm always available to help.
As always, it's great to have you on and learn from your wisdom. I appreciate your time, Craig.
Thank you very much.
Have a good day.
Craig Ferreira has been around the PT block thousands of times. He knows the inner workings better than almost anybody and can break down any situation into easily digestible nuggets. Thus, I had to have him on when I found out that he's about to give a talk on how to improve productivity and, specifically, sales in the PT setting. Most PTs hate "sales" as we know them, but doing it in the right way isn't "sales" at all. How we present that to our teams can be super easy. Craig knows how to do it. If you simply do a little footwork, have some conversations, practice the art of "selling," create and hold expectations firmly, then just wind it up and let it go, you can see results quickly! Follow Craig as he'll walk you through it.
Love the show? Subscribe, rate, review, and share!
My guest is Greg Todd out of Florida. You might have seen Greg around. He's got a ton of stuff going on. He's the owner of multiple PT clinics. He is the Creator of coach and consultant companies called PT Builder and Smart Success PT. He's a mentor. He's a fellow podcaster. He's got a great event coming up. Look out for that. I'm excited to bring Greg to you because in his story, he came to recognize early on in his career, and that was even prior to owning his PT practices, that it wasn't the traditional PT skill set that was going to get him where he wanted to be in terms of success, significance, the effect on his community that he wanted and the wealth that he wanted to achieve, and even the freedom that he wanted to have in his life. He turned to recognize that he needed more non-traditional skill sets and the build-up of those skills. Whether that was learning how to lead others, doing better in marketing and sales or at least having the ability to communicate better with other people and becoming the visionary of his own life and the visionary of the companies that he wanted.
I'm excited to bring Greg to you because it harkens back to the same message that came upon with my interview with John Woolf where we recognized that it requires a change of mindset, that it is not the traditional skill set that's going to get us further as PT clinic owners to achieve the goals that we want to achieve. Read into Greg's value stages that he brings up for any member of a company, whether you're an employee or the owner, and how that correlates to the amount of money and freedom that you have in your life. That's invaluable. He also talks about four different types of people that exist in the world. I'm sure you can relate to all four of them, whether that's yourself or others that you've come across. I will let Greg put his own words to it. Read his story. You will get a lot out of it because he brings a lot of energy and a lot of wisdom to the story and to the message that he's carrying forth.
I’ve got Greg Todd, a physical therapist out of Florida. He is the Creator of Smart Success Physical Therapy and also the Co-owner of three physical therapy clinics and soon to be four. Todd, first of all, thanks for coming on. I appreciate it.
It's my pleasure. Thank you for having me. I appreciate it.
Tell me a little bit about you, Greg, where you started from, what got you to where you are and what you're doing nowadays.
I've been a physical therapist since late 2000 and got into the field because my mom told me to. My mom was a medical transcriptionist for an orthopedic surgeon. She told me and indoctrinated me that, “Greg, you need to have a skill.” She loves her husband but, “Don't be like your dad.” My dad was an entrepreneur and he used to work for a company called Primerica. She says, “You want to have a stable job. You want to have a skill so that you can get a job when you get out of college.” Initially, she wanted me to be an orthopedic surgeon. The orthopedic surgeon that she worked for, the day that I went to go meet him and shadow him, he was in a pissy mood that day. He said, “Don't do what I do. I'm on my third wife. My kids don't know me. Do what they do,” and he had physical therapists that worked in his office.
That is the story of why I decided to go into physical therapy. I knew that I needed to get a stable job because my mom told me to. I knew that physical therapy was in demand. It was between physical therapy and pharmacy. I've always wanted to do physical therapy because I love sports, but I was leaning towards pharmacy because I had a speech impediment and I stutter a lot. I was very afraid that I wouldn't be able to communicate with clients because of my stuttering that I struggled with all my life.
I ended up deciding on PT and that's how I got into it. I was not planning on being an entrepreneur. I just wanted to work 9 to 5, come home and have a good living. I always knew I wanted to have a family. Within four months of me being a physical therapist, I was married to my college sweetheart. I quickly realized into the profession that there was a hard ceiling and it wasn't necessarily the money, but it was the time that I wasn't able to get back with the hard ceiling that I was experiencing. We had our first child and then that turned into two, three, four and I realized that this is not going to work. It's such a hard salary cap and more importantly, it was such a hard time cap. I realized that I was not going to be able to ever win the time game if I was just a staff physical therapist.Communication in the real world is treating everything like an advertisement. Click To Tweet
I thought that I was going to reach my ideal pay by year ten. My first job, I make $39,500 a year. My plan was to make a 4% increase every year. That wasn't bad back then because I was coming out in 2000, 1997 is when the Balanced Budget Act came. You are lucky to have a job. $39,500 and I had a full-time job. I was like, “We're good.” I was making $7 at the most. I'm like, “This is great. No problem.” The issue was that I was under the assumption that you're going to get a 4% increase every year and I had a plan to make $50,000 by ten years. I know it sounds crazy now, but back then that was like, “$50,000, I'm going to get a 4% increase every year. I'm going to hit the corporate numbers. I'm going to hit the company numbers. I'm going to take care of patients. I love physical therapy.”
On my first year, the company that I was working for was a big corporation. They had continuing education courses every single weekend that were company funded and that was within the company because it's such a big company. I did 180 CEUs in my first fifteen to sixteen months. I thought that was the way to achieve the 4%. I had done over 100 continuing education units by month twelve and I've got a 1.5% increase in pay. That was the first a-ha. When I went to my boss, I was pissed. I'm like, “Why did I only get a 1.5% increase in pay?” He was like, “You didn't do anything wrong. That's what we give for staff PTs.” I was like, “How do I get an increase in pay?” She says, “You’ve got to be a clinic director.” Now, I understand how the whole levels of earnings work. It was the first time that I realized you don't get rewarded for being a better clinician in the real world. You get rewarded for moving up in management and you get rewarded for other things, but you don't get rewarded for clinical excellence, which is sad but it's the reality of the situation.
That's no different than being a PT owner. You don't get rewarded for your skill set.
You get rewarded for running the business right, but I didn't understand that and most people don't understand that. If you think about it, it doesn't make sense because we put so much effort into CEUs, into this and that. You've got to get this. You’ve got to do this. You’ve got to become a CSCS. You’ve got to become an OCS. You've got to become an SES. You've got all these different things but nobody talks about that does not get you any closer to having financial freedom and any closer to having time freedom. I went through this journey for about three and a half to four years. My wife and I started to have marital problems. It’s nothing crazy. She was frustrated that I was working so much and that I was on this quest to do every single CEU course there was out there. At that time, I also got the opportunity to work with professional tennis players. I was working on the WTA and ATP tour. I was trying to become an OCS. I was trying to get every single manual therapy certification there was on planet Earth. At the end of the day, I was getting nowhere in terms of earning more and getting more time freedom.
Where it culminated for me was when I asked my boss where I was a clinic director at a brand-new clinic. I had achieved the numbers that they wanted after a year of working in that clinic and gone beyond 50%. I said, “All I want is one day off a week. I want to work four twelves. You are paying me a salary for 40 hours anyway. Let me work four twelves and let me get that one day back so my wife and I can start to spend more time with one another,” because that's where the frustration is coming, that I'm never there. He said no. That was the day that I knew that it didn't matter. I had to become an entrepreneur. I had to go and open up my own thing so that I could be in charge of my schedule. I did not want to do this, but they forced my hand and that's it then.
It wasn't tragic but in a sense, it's a challenge. It’s not even failure but something took you to the point where, “I've got to do something different.”
I’ve got no choice. It was either that or the marriage. They made it very clear. Just to give you an idea of my schedule. People may go like, “What was your schedule like? Was your wife being a brat?” No, she wasn't. Here is my schedule. I started seeing patients at 7:00 AM at the clinic I was working at. This is a company called CORA. I was seeing patients until 8:00 PM. When my tennis players were in town and they weren't out of the country for tournaments or whatever, I was going to their houses or their condos in a place called Saddlebrook after work. It’s about five to ten minutes from my clinic. I was going there and I was working with each person an hour to an hour and a half at a time. I was sometimes leaving Saddlebrook at 11:00 PM.
I’m getting home by midnight to 1:00 AM, eating, then staying up until 1:00 AM and she's asleep. She's waking up to take our daughter to her mom so she can go to work. This was the normal day. Then the weekends were going to Continuing Education Courses. At that time, I was trying to get my Manual Therapy certification to the University of Saint Augustine. That was Monday through Friday for us, then Saturday and Sunday, I was in Saint Augustine trying to become this better clinician. It was a rat race to the bottom. That's all it was.
I love having you on because I'm all about stability and freedom. My story is similar. I wanted stability and freedom, unlike my father. Something that could give me the opportunity to be like my uncles who were in the healthcare profession. They had time and money, and I wanted that. I love having you on because that's what I'm all about on this show. Was it at that time that it finally clicked for you that your clinical skill set made no difference or did that come up a little bit later?
At that time, I started to get it but I didn’t still fully get it. I've started to realize that I was blaming the companies. I was like, “I think they're trying to screw me over. What I'm going to do is I'm going to leave and I'm going to open up my own thing.” I had a non-compete so I had to leave the area for one year and then I came back. During that time, I ended up with this guy who saw that I was working with all these tennis players because the tennis players followed me. He had a very small clinic called Renewal Rehab. He's like, “Let's team up. You will have all the insurances if you work with me.” We decided to become partners. We’ve been partners for fourteen years.
At that point, I still think clinical didn't mean anything and it does mean something. What I did realize at that time was that the corporate system wasn't set up for me to be autonomous, for me to make decisions, for me to do things that I feel were in the best interests of the patient. I knew that at the time. I knew that enough to say, “I’ve got to get out of their system.” I thought that if I went on my own, all these awesome things that I had: OCS, CSCS, all the Manual Therapy courses that I did, and all these different things were going to flood all these people to me. At one point, I was working with three either current or former number one players in the world. I truly thought everybody was going to come to me but it didn't work like that.
You had to come to the realization after stepping aside, working with this other guy and partnering up with him that patients didn't show up, I assume.People are interested in stories. They're not interested in facts. Click To Tweet
There are a couple of things that happen. At that point, I was still working a lot with physicians. I had verbal agreements that, “When I come back to this area, will you send me patients?” They’re like, “Yeah.” Until you come back in the area and you say, “I'm open,” they don't give a crap. There are a lot of things that I had to come to terms with. A lot of PTs think, “If I know this person, if I have this certification, if I do this, if I know dry needling and if I know that, all of these people are going to want to come to me because they are going to want the best.” That's not how it works. That's not how the game works.
What are you telling owners nowadays? What's cool is you're also working with physical therapy students and telling them what the game is like. What are you telling them to focus on? What are you telling them about the system? What do you encourage them to do?
I'm explaining to anyone that wants to get clients into their door, “No one gives a crap about you. They just care about themselves.” That's the main thing you have to understand. The big thing that I'm telling them is everything that's in life or the way that things are with your clients is they don't give a crap about you. They don't give a crap about your certifications. You have to learn how to communicate with them at a very high level. When I say at a high level, I'm talking at a low level. That means we have been trained to communicate the way that we communicate with our colleagues. That's not how it works in the real world.
In the real world, you have to treat everything like an advertisement. You have to talk to people in a way that they're interested in. You have to be able to do things that are going to connect with them for their needs. That's not something that we are trained on. You have to hook people. People are interested in stories. They're not interested in facts. I was trained that the way you need to do it is you need to bring out your JOSPT or the journal article but nobody gives a crap about that. I had to train myself that the higher level of communication is communicating at a third to fifth-grade level with people. That's the big thing that I tell owners. That's what I'm having to do for my clinics and make it very simple for people to understand what it is that we do.
A lot of your focus then is on what people might call soft skill set. It's sales, marketing and patient engagement. It's interacting with people and building relationships.
I'm going to tell you what one of my coaches trained me on. I don't think most people understand this. At my conference, I have him speaking three times because I know that people's minds will be blown once they understand how this works. What he trained me on is that there are four levels of value. We have been trained for our entire life pretty much at the lowest level of earnings, which is implementation. Let's talk about the four levels of value. Implementation is the lowest level. The next level is managerial and unification. That third level is communication and the fourth level is imagination/vision.
Let's break it down. If you take the lowest level, which is implementation. Implementation is somewhat like if you go to a hotel and you want your room cleaned. You want to make sure that your room is clean day-after-day that you're in it. If you check into a hotel and the room wasn't clean, you'd be pissed. You'd be like, “Can somebody clean the room?” That's not a good experience for you. That's a low level of implementation. Someone that's like a maid or a cashier at Walmart. As physical therapists, we are also at the implementation level as well. It is the lowest level of earnings there is. The next level and I didn't realize this when my boss was telling me this in 2001. She was saying, “If you want to get higher than 1.5% increase of pay, you need to become a clinic director.” What she didn't even realize is that the next level is managerial. That is someone that's overseeing all the implementers. You get paid more to make sure that the implementers don't kill themselves, don't kill each other and that they give a good service to your customers. That's a higher level of earnings. Not a lot but it is a higher level of earnings.
In the corporate structure, that brings more value.
When I look back now on my journey in 2004, that was what my boss was telling me. My boss was saying, “If you want to go up in this company, you need to go into regional management.” That's the only level to go. There's no 97110-OCS code. It's 97110. It doesn't matter who does it. It doesn't matter if there's a 97110-eighteen years of experience. It doesn't matter if there's a 97110-36 years. There's a 97110 code. It's just for implementation. There is no way that it's going to pay you any more. What I realized is that if I can go up more in management/unification, which is the second level of value, you can get paid more but it's still a hard cap. There's only so much you can get up the corporate ladder. Here's what I've come to understand. The third level is communication. Meaning that if I can learn how to communicate, if I can learn how to market, if I can learn how to do the hardest thing for any business, which is to get clients and keep clients, it is the highest level skill that you can have.
Think about the people that make the most amount of money in this country. It is the best people that are in sales and entrepreneurs. Entrepreneurs are salespeople. They're selling you on their vision. It is the high-level authors. The first job I ever had was a sales job when I was fifteen years old. I sold newspapers for a company called the Sun-Sentinel. I made $11.50 over two weeks. I sucked in sales. Now, I'm good at sales. I did a webinar and I made $138,000 in two days. It's a skill that if you get good at, you can make a lot more money. I was watching Kevin Hart's Irresponsible tour on Netflix. That guy makes gazillions of dollars by doing a stand-up act for an hour. It's something he's got good at. The best singers make a ton of money. It's all communication. It all falls under the communication umbrella.
They’ve got a robust sales program in social media, you name it, it’s all about sales. You build a brand.
It's all communication. Best actors, best singers, best authors, salespeople are all great communicators. Communication is an amazing skill to have. That's why it's the second highest level of value. Then the top level is the visionaries. It's like this. When you think of Apple, who's the first person that comes to your mind?The people who make the most amount of money in this country are those that are best in sales. Click To Tweet
It's interesting that you didn't say Steve Wozniak, because Steve Wozniak was the person that actually built the machine. You said Steve Jobs because he's the visionary. At the end of the day, the visionary is the one that’s like me having the vision of this program called SSPT. I make the most because I was the one that envisioned it. I was the one that was able to sell the program. I was the one that was able to build a mission and turn it into what it is now. I get paid the most. That's what people don't understand. They don't understand that throughout your entire educational system from pre-K to grad school, you've only been taught at the lowest level. It sucks but it's also optimistic because it's like, “If I go and learn these things, I could accelerate my income and my earnings to astronomical levels.” That’s what I try to teach people.
You had to go down this path yourself to figure it out that you were losing money or at least you weren't tapping into your potential as long as you stayed an implementer. To those physical therapists, I know you've come across them, that are still working on patients, what are you telling them? How are you getting them into increasing their value and getting out of that?
I don't have a problem with people working on patients. The big thing that I need people to understand is that you want to make it a goal to do more things at the higher levels of value than just stay at the implementation level. I'm not saying for people to go from, “I've been treating patients for the last one to twenty years that I've been a clinician and just go cold turkey away.” I'm saying to respect the other things and start to work your way up to those other levels of value so that you can now burst through the ceiling. The reality is most people aren't even paying any attention to it. They're frustrated. They're like, “Why does my career suck? Why am I burning out? Why is this happening? Why is that happening?”
They don't understand those four levels. They don't understand this is how it works. They don't understand that every single CEU course that you go to, what does it teach you? How to implement more. There's no CEU course out there that is saying, “We're going to teach you for a day and a half how to implement, but then we're going to take the other day and a half and we're going to teach you how to communicate what we taught you.” Nobody does that. They don't even know it. I figured it out and it was my coach who put the pieces together for me. He was like, “This is because it's the four levels of value.” I'm like, “That makes so much sense.” That's how my whole career has gone.
Tell me about that a little bit because I'm a big proponent of coaches. You've got to step out and recognize that you're not creating more value by simply treating patients all the time. You've got to be a visionary if you're going to own a practice, make more money and have more stability and freedom. I highly believe that coaches and networking are integral to making those steps. Tell me about your journey towards getting a coach and working with a coach. Did you start right off the bat or did you get to a point where you’re like, “I need some help.”
Let me bring it back to maybe 2004 or 2003. My older brother has always been the entrepreneurial type. I've always been the anti-entrepreneur. That's how it was in the family. I just wanted a stable job. He was always the one coming up with ideas and this and that. He's always been telling me about Tony Robbins, about this person and about that person. I’m like, “Whatever.” I always thought that personal development meant that something was wrong with you like you needed to see someone. I didn't understand the whole thing. It wasn't until I experienced pain as in the way that I thought things were going to work out is not working out, that I started seeking out direction. My older brother was probably one of the first people that I'm like, “Maybe you are right. Maybe I should go open up my own thing.”
From there, I never got my first coach until 2012. I started realizing the power of having how much people knew that I didn't know. I always thought that coaches were CEU like continuing ed people. I realized that there was another world out there that I had not even tapped into. It was in 2011 or something like that when I went to my first real event. I started realizing that there is so much crap I don't know. I started looking, “Is there anybody in physical therapy that does this?” Nope. There's no one in physical therapy that does this stuff. I had to take coaches from outside of my profession, learning and then how can I implement and incorporate this into what I do? That's what I did.
I realized that there was definitely a need to have people that thought the way that my coach has thought and be able to apply it in a field like physical therapy where people have no concept to any of these things. Now, I have many coaches. I have one person that I've employed as more of my mentor and then I have coaches for different things, those different levels. I pay a lot of money to have coaches because I'm realizing that you tell me one or two things and it can be the difference of doubling my businesses. It could be the difference with allowing my missions, all the things that I'm doing to take it to another level. I believe in self-education and I believe it has catapulted my career infinitely more than traditional education. I'm willing to pay for it.
I love that you shared your insight on that and especially what you pay for it. You didn't share dollar amounts.
I pay over $100,000 a year.
I've done the same in the past. What it turned out to be the following year was easily double that in increased revenues. It's funny because I will talk to friends who are like, “I'm thinking about getting a coach, but this guy wants $10,000 for a year and they're hemming and hawing.” I'm like, “You don't even know that $10,000 investment could triple, quadrupled or do more in the next six months to twelve years that you don't even realize.”Convincing is getting you to do it for my reasons. Persuasion is getting you to do it for your own reasons. Click To Tweet
Nathan, I want to tell you something that's important about this. I was Facebook Messaging a guy that's like, “I've been listening to your podcast. I've been doing this and doing that. I'm ready to take this one course that you have. Tell me something to get me over the edge.” I was like, “Here's the deal. I don't convince people. I'm not into that.” I do persuade, but I don't believe in convincing. Convincing is getting you to do it for my reasons. Persuasion is getting you to do it for your own reasons. I need to have you come to the conclusion that this is in your best interest. I'm going to say the reason why people are like, “Yeah, but I don't want to get screwed over by a coach.” I was like, “This is why every single coach I've had, whether it's been a great experience or not a great experience has been beneficial for me.”
We are in a profession where everything that we've done, for the most part, I'm assuming the majority of your audience have only done traditional education. People are like, “How is it that you're able to do all these things?” I have a $30,000 coaching program that people work with me for a year and people are like, “How can you get to the point where you charge that?” I was like, “It's when I started paying for it myself that I realized that my worth has gone up.” I can tell the person like the one you’re talking that's like, “$10,000 or $15,000 or $20,000.”
What I've learned is that there are four different types of people out there. This is something that my coach taught me as well and I will share it with you. There are feeple people, there are freeple people, there are cheaple people and there are premiumple people. This is how it works, but it makes perfect sense. I can say for me, it has changed everything in my businesses when I understood that I've been all four of those people. The first person is freeple people. These are the people that want everything for free. What ends up happening is that when it's time for them to sell anything, they have a hard time selling anything. They're so used to getting everything for free that they feel like a hypocrite for charging. The problem is nobody gets results in them because if you give me free stuff, you don't take it seriously. It's the way it is.
Then you have cheaple people where everything they want are discounts. The thing is when it's time for them to get people to buy into their stuff, they're discounting everything. What happens for them is they're like, “I give so much and I'm not getting anything for it.” Those people end up quitting because they're not charging their appropriate fees. Then you have feeple people. They are people that are comfortable with paying a fee. They don't want to pay for the best, but they're comfortable with paying a fee. What happens is in return, you get people that don't want to treat you as the best. They just want to treat you as, “Okay, you're decent, whatever.” Then you have premiumple people. Premiumple people is where I finally got myself as somebody that used to be a feeple person and now I'm a premiumple person. I’m willing to pay premium for the best.
I have my event and I'm paying someone $25,000 to speak at my event because I want the best. I've looked at my bill so far for that event and I've racked up over $100,000 of bills because I want to have the best of it. I will make a ton of money because I'm willing to accept it. I know that I only give the best so I don't have any hiccups with, “First, he was going to pay me $2,500 a month or $30,000 for the year.” I have no problem with it because I know that I give the best of my people. I don't even know how to not give the best. I've had to train myself to get to that level. I think most people don't understand that and they have this hang-up with selling, “I don't want to sell.” You don't want to sell because you're a feeple person. You probably get everything for free. You should feel awkward. It's like me cheating on my wife and asking her to be faithful to me. It doesn't make sense. That's not how it works. If you're faithful to me, I'm faithful to you. If you love me, I love you. If you don't love me, it's hard for me to love you. That's the way it works and most people don't get that.
It comes back to mindset. You hear about the mindset of abundance and making sure that, “There's plenty of it throughout the world,” instead of a mindset of scarcity, “There's only so much of it out there. Whatever you got, you’ve got to keep it. Someone's out there to screw you over.” Instead of thinking, “There's an abundance of money to be made out there. There's an abundance of love to provide to people. There's an abundance of knowledge to provide to people. We can all share in this boat together.” Switching from that scarcity mindset to an abundance mindset is hard for some people to get over.
I've been there. It's very difficult for people to get over. I'm at a point in my career where I have four kids. My wife's love language is time. I don't have to work anymore. I have an exit plan where I don't have to work if I don't want to. I want to do this but what I have come to understand is my wife would prefer that I hang it up. She's made it very clear. She says, “I would rather you hang it up because you're giving so much to people.” What I've noticed is this. I started Smart Success PT on May 29, 2016. It was for one year that I was coaching and educating people for free.
Do you want to know what my show up rate was for the calls that I did? At this point, I'm only working two days a week in my clinics. I only do evals, everybody else does all the other stuff. I had all this time for myself and my wife, but I told my wife I want to help out this new generation of physical therapists and teach them the things that I've learned. I would block off six to eight hours a week for complimentary coaching calls with me. My show up rate was 30% because I was giving free stuff. I was attracting freeple people and they didn't respect it. What I did was instead of me hitting the dream at 38 years old back then when I started this whole SSPT thing, I was creating another nightmare in my marriage. My wife's like, “Here you are taking time away from me to give to these people that don't even value your time.” Now, I have to charge $30,000 a year because now my show up rates are 100%. It actually saved my marriage. We don't need the money. I don't want people wasting my time.
You have to recognize that you provide value and you’re worth something. There's something to that. There has to be a monetary obligation. Otherwise, people do exactly what you're talking about. They keep in the value of the service that you provide if you're not willing to charge a premium for it. That's a constant battle for physical therapists because at our core we feel we should give away even our services for free. We feel bad asking for a co-pay. We feel bad for asking for a deductible. It hurts to our core to ask people for money. We've got to get over it.
We've never been trained on any of this stuff. That's why everybody struggles with it. They've never been trained on value, personal development, how money works and that you not collecting the money from people is hurting them with regards to getting them to commit. There's so much stuff. Trust me, I struggled with that as well. I struggled with it mightily. Then people are shocked when they get canned. It's like, “They cut my hours. How did this happen?” It happened because nobody paid attention to money. Nobody paid attention to value. “I don't know why patients are canceling. Maybe it's the weather.” No, it's not the weather. The value's not there.
Here's the interesting thing. I give the most amount of free content out. I have 900 videos on YouTube. I've been doing this four to five days a week for four years. You could see that I go on Facebook Live pretty much every single morning and I turn it into a podcast as well. I'm on episode 500 of my podcast. Here's the deal. I give out free stuff because I have made a commitment that I'm going to dedicate six hours of my week to serve my healthcare profession. I'm going to give out but everything else is paid. This right here is one of the six hours. When I and you talked, I knew that I had one more hour this week of my six hours that I give away. I was like, “No problem.” This is one hour but after that, if you want to work with me, you have to pay.
What has happened though is that people have seen, “This guy gives so much value for free. What does his paid stuff like?” It's not a problem for people to pay me money and they pay me a lot of money. It's no problem. When they pay, they realized, “This is worth it.” I've had 475 people take my course. It's the only online course that I've never had a full refund. It's never happened before. It's a $3,000 course. That's the entry level to work with me. The deal is that we have to get over this whole money work that we have. You've been taught that money's evil. You've been taught rich people are stingy, this and that. There's so much crap you've been trained on. You've been indoctrinated on that so that you would stay at the lowest level of earnings, which is the implementation level. What people don't want you to know is that anyone could get to the other higher levels, but then it screws up all the people that are at higher levels. Now they don't have implementers and they're panicking. That's why I'm getting so much flak from different establishments because they're like, “This guy's turning all these people into entrepreneurs.” Now they're all waiting, “Who's going to work for us?” It’s freaking people out. I'm having fun with it. I'm loving it. I love watching all this happen.Your Value, and thus your Earning Potential, increases as you climb up through these stages: Implementor, Manager, Marketer/Communicator, and Visionary Click To Tweet
You're doing great and I love the energy that you bring in. I know that you have a conference coming up. Is your conference a lot of this like how to market, how to sell, how to change the mindset or am I off base? Tell me what is your purpose.
That's what it is. It's called SSPT Live, which is my flagship course, Smart Success PT. The conference is three days. It's based on how I have my method set up for SSPT. The first thing that I believe everybody has to do is they have to calibrate themselves. We have to change their mindset. They've had a worker bee mindset, “This is all I can do,” and we need to help to calibrate people. It's like having a compass. We need to know where we're going first. The first day of the conference what I do is I'm going to show everyone there's not one way to do it. There are many different ways to do it. The people that I've been coaching that are now at a level to where they're at the top 1% in earnings in physical therapy, I've been able to do it for our practice owner, for mobile concierges, for people that are doing online coaching, strictly online, canine physical therapists. I've been able to get all of them, at least one person beyond the 1% in PT.
The first day is about giving you the belief that you can do it in any way that you want. The second day of the conference is about teaching you those higher dollar value skills: the communication, how to be a leader and how to have a vision. That's what the second day is about. If we can focus you on the first day and then we can start to teach you those skills, the third day is about giving you the ability to have a legacy. It's showing you. My whole thing is calibrate, care, create. Calibrate you and getting you focused. Care is showing you the high dollar value skills. They are true care skills that you're going to need in order to win and then create. Create wealth, time, financial freedom. Until you create those things, you cannot create a legacy. You don't have the time to do it.
People say like, “It's such a nice ride.” There are many nice physical therapists out there, but they've never created time and financial freedom. They can't do the things that I'm doing. They are good people but they can't do it because they have never focused on creating time and financial freedom. They can't give back, which sucks. Overall, if you think about it, our profession typically attracts people that are good at the core, but they suck with making money and with knowing how to create time for themselves. They can't do anything impactful.
That's where you see a lot of burnout. You don't see a lot of 40-year-old practicing in physical therapy out there. You get to the 40-year-old mark and you're looking at you can't be a staff physical therapist anymore if you've been a manager for a period of time. There's a hard ceiling there. They're not fulfilling their potential. They're looking for other things. They will get a realtor license or something like that.
Do you want to know what the sad thing about it? When you think about it, the entrepreneur is always telling the implementers what to do. The problem is that in our profession, you don't have enough entrepreneurs. I'm an entrepreneur and I have clinics. Why is it that my employees are happy? They're happy because I am an entrepreneur, but I'm a physical therapist at heart. I want to set it up so that my people are happy day-in and day-out. I have a very unique set up at my office to where the culture is amazing at all three of my clinics. Here's where the problem is in physical therapy. The problem is that most entrepreneurs that are running physical therapy locations are not physical therapists.
They don't have that, “We need to do what's right for the patient, but we need to also do what's right for the physical therapists.” They don't have that pull. What's happening is they're like, “Blue Cross Blue Shield has decreased by 10% in pay, add more patients in the schedule.” Easy fix, go work harder. What's happened is that the entrepreneurs never had that moral code entrenched in them on what it's like the moral code that we have as healthcare practitioners. This is the reason why I'm trying to create many entrepreneurs in healthcare so that when they grow, expand and scale their businesses, they now have already indoctrinated them the moral code of a healthcare practitioner. Whereas if you think about it, most of the people that are running these big organizations are not healthcare professionals. They don’t care. They only care less.
I know you've got to get going. You shared a ton of content. I'm sure we could go down another road with another topic, especially that one in particular. Unless you have something more to share, make sure people get your content or at least your contact information.
You can find me @GregToddPT. That is my handle on Instagram and YouTube. If you want to opt-in to my mentorship list, I send out an email every single Monday called Mentor with Greg. It's something that is on my mind that I feel I can help people. I've been doing it for two and a half years. That's MentorWithGreg.com and you can opt-in to that. My event is SSPT Live. We’re nearing in 500 people for the event. That's pretty awesome. On Facebook, it's www.Facebook.com/ThePTBuilder. I go live at about 7:30 every morning. I usually do a 20 to 25-minute talk of whatever I feel can help people. I also turn it into a podcast and the podcast is called The Hunt for Greatness. I'm everywhere. If you want to binge on my stuff, you can binge on it as much as possible. You will be bingeing for months.
The stuff that you're sharing on your Facebook webinars and also your podcast, is that stuff specific to PT or is it more business in general?
It's for everyone but I have an affinity towards physical therapists. My program has taken in the first five or ten OTs, we have dieticians, chiropractors and we have people that are not even in healthcare. It's going beyond because at the end of the day, if you think about it, no one's learned any of this stuff.
A lot of it is basic business principles or entrepreneurial principles that are beyond just the PT.
It's funny, 10% to 15% of my people aren't even in physical therapy school yet. They're learning the stuff and they understand, “I'm taking this information. I could become a consultant.” They're making money to pay off their entire physical therapy education. I teach people how to create money. That's what I want to teach you. If you can learn how to create it, that money is just exchange. I'm teaching people to be more valuable so that you can make whatever you want.
Thanks for your time. I appreciate it. I wish you the best with everything. I appreciate it.
Thank you so much, Nathan. I appreciate it.
For the past 18 years, Greg has dedicated his life to helping people with the skills that he has learned in his physical therapy career.
In the last eight years, he has helped thousands of people in physical therapy (and now other allied health professions) because of the skills that he learned beyond traditional physical therapy schooling.
This has led him to live the life of his dreams for himself and his family, and now helping others, just like you, create the life of their dreams for their families as well.
Dr. Dimitrios Kostopoulos passion for physical therapy is obvious, and his vision is unique and outside-the-box. He has a number of PT businesses and is successful in each one of them, thus he has a unique perspective on the state of physical therapy and the issues negatively impacting PT clinic owners and the profession today. However, he also has the answers to the three issues he presents. Following thru on each of those items will put you on a path to freedom, but if you don't take the time to study, implement, and do the administrative footwork necessary to run your business, you won't make it. Dr. Kostopoulos shares that that knowledge on the subject provides a greater responsibility in the area that you are learning something about, and knowledge, responsibility, and control always go together.
Dimi, thank you so much for taking the time to be on my podcast. I was excited to bring you on as a guest simply because over the time that I've known you, you have so many things going on in your life business-wise. I figured I need to talk to this guy and see how he gets things done. How is he so effective and productive? Dimi not only owns and practices in his own physical therapy clinics in New York, he also owns the HODS company, Hands On Diagnostic Services, where he not only provides electro-diagnostic services for physicians but also trains physical therapists in electro-diagnostics. He does a significant amount of work in the APTA. He has a professorship, am I right, Dimi?
Yes, at the SAU school of medicine.
On top of that, he's doing research and he’s at all the APTA events. The man is busy, the man is productive, and he's definitely successful. I’m anxious to bring you on, Dimi. You've been a great influence in my life and honestly one of the reasons why I'm in Alaska. For the audience, would you share your story what got you into PT, what got you into physical therapy ownership, and to the point where you are now?
First of all, Nathan, let me just say, what an amazing work you are doing with this podcast and what a gift you are with this podcast to the physical therapy profession, especially private practice physical therapy.
Thank you. Keep going.
We can start talking about each other accolades here and the feeling good, but the bottom line is let's get into something that people can be helped and we can give them some information and some advice that they can find useful right now in what they are doing in their private practices. You asked me why I got into physical therapy. I did not. They just put me into physical therapy. I was born, grew up, and went to school in Greece. The educational system in Europe is a little different than in the United States. What you do there is you choose an area of interest which can be either generally the medical sciences or generally the sciences of physics and math and all that, or then philosophy. Depending on the area that you are choosing, you take special exams and they just put you based on the score you got into a specific area. Physical therapy was not my first choice by the way. It was actually my second choice. Medicine was my first choice. Physical therapy was my second choice, but I did not score that high so they put me in physical therapy. I took it as it went.
I finished physical therapy and during the time I was starting it, it was awesome and I fell in love with the subject after I was exposed to it, not before. When I finished my studies in Greece, I came to the United States to do graduate studies. I worked for a couple of years in hospitals, but then in 1992, I decided to open my own private practice and this private practice very quickly, in a few years, grew to multiple practices. My business partner, Kostas, and myself from 1992 to about 1997, 1998 ended up creating and developing thirteen physical therapy practices doing 2,400 to 3,000 visits weekly. We were the second largest physical therapist owned private practice in the New York state.
Was that difficult to ramping up, the sheer magnitude of that? How were you able to maintain it?
From 1992 that we started the practice until 1995, the first two and a half, three years, we went just from one office to two and a half offices. In the middle of 1995, beginning of 1996, we’ve got involved with a consulting firm called Survival Strategies. From Survival Strategies, we’ve got very intense instruction, courses, and programs that helped us develop the practice. From the end of 1995, we literally started opening a new office every couple of months. Towards the end of 1998, we had thirteen physical therapy locations.
Why did you decide to reach out to the consulting firm? My target audience is the independent patient practitioner who has his own clinic and there, of course, are other physical therapists who are more established, but they might be in that boat where they're considering consulting or they haven't reached out yet. They don't know who to reach out to. What led you to reach out to the group Survival Strategies? Was there a turning point or something that made you think, “I need to do this?”
It got to a point that I was so confused because I had zero knowledge in how to manage a business. I did not know management. I did not know how to manage finances. I had no idea how to market. I was going out there to meet a physician and I was going with an attitude, “I’m Mackenzie-certified and I’m Maitland-certified, and I’m this and I’m that.” Who cared what certification I had. It was not effective.
You noticed that you were losing control in your business or did you have a particular incident that sets you off?
I started not sleeping at night. Seriously, I was very stressed out because I did not know how to handle things. I was feeling, “How am I going to handle my payroll? Why I did not save money last month? I did not think that I will have more expenses this month.” I was not thinking in an organizational way. I was not planning properly. This is finally what changed. There were a lot of things that changed when we sought help from a consulting firm, both in the management area of the practice and also in the way we approach the community. The way we approach the referral sources changed tremendously too and made a huge difference.
After gaining some organization going through the consulting, there was a quick change and effect that led to continued growth in your physical therapy practices at the same time. Did that include the continuing education part of your company?
Yes. We started in 1994 the continued education company and we started offering courses in manual therapy since 1994. That's hands on seminars at www.HandsOnSeminars.com. Here is the thing I wanted to mention, that knowledge on the subject provides a greater responsibility in the area that you are learning something about. Therefore, you can control that better. Knowledge, responsibility, and control go together. You acquire knowledge about something, now you take more responsibility because you have more knowledge about that area, let's say the private practice physical therapy area, and therefore you can control that area better. There is another equation which is magical, control equals income. The greater the control you have in a business, the greater the income you can get from that business.
I can totally see that as we're talking about it, considering you're not alone. A majority of us, 99% of us physical therapist that own our clinics, don't have the business knowledge. We all have these same characteristics where we become very good practitioners and some of the better practitioners in our professions, yet we don't have the business knowledge. That's what leads to the confusion that you experienced, to staying up at night, the disorganization in our lives both professionally and turns out to affect us personally. As we gain that business knowledge, and we have to do that, we have to set aside the time to educate ourselves whether it's through a consultant or some other means, some resource, whatever that might be, to learn about business. As we do so then, we organize our lives, we become more responsible, and we have more control. Thus, we gain more power and we gain greater income.
I'll give you some data about the income aspect that we're talking about here. A few years ago when we established a hands on diagnostics, the national franchise that helps physical therapist developed diagnostic testing services within their facilities, we paid an independent survey firm over $50,000 to do a survey to physical therapists around the country. The number one issue that private practice owners have is reimbursement. Here is what happened in regards to reimbursement to me. We developed all these clinics, we had a beautiful run for several years, and in 2004 in New York state we started receiving a series of letters from the insurance companies where they were decreasing their reimbursement rates by more than 50%. Imagine that in November of 2003, you are receiving from Blue Cross Blue Shield $140 a session and then you are receiving a letter that effective January 1st, your reimbursement will be a flat rate of $55 a session, take it or leave it. That’s painful, isn’t it? Then Aetna follows and United Healthcare follows and the other insurance follows. 90% of insurance companies in New York State end up slashing their rates by 50% to 60% at least, so we had to do something about it.
That was probably another time in your life where you were staying up late at night, I assume.
Totally because although we were holding in our hands the golden goose or the golden egg, we could not see it. We did see it finally looking more carefully on our financials and our statistics.
You were on top of your financials and your collections. You’ve got the letters but then you started seeing the cold hard numbers and you thought, “I've got to do something different.”
At that point, this was a pretty large organization. Sometimes making changes in a large organization, changes take place but it might be a little slower until the changes go all the way down to the line of command when you have under you 150 employees to manage. What happened though, Nathan, is we realized that although reimbursement for physical therapy services were cut so deeply and we were hardly making any money from physical therapy services, the diagnostic services that we were providing at that time, predominantly electromyography nerve conduction studies, were yielding for us at least ten, fifteen times more than a physical therapy session.
You were doing the EMG nerve conduction studies prior to this?
Yes, since the late 1990s. Once we realized that, it totally changed our entire business model. It totally changed our focus. We started dedicating time and energy and effort in identifying how we can properly incorporate a variety of diagnostic services within our physical therapy practice. Fast forward in 2018, right now we have only one single physical therapy practice. The rest we have sold and we cashed out to our clinical directors. We did not sell out to a company, we sold out to the clinical directors. When you sell out to one individual, one company's much easier for one person who is working within the practice itself to actually make money from it. At this point, we only have one physical therapy practice which is doing very well, but despite the fact that it has high numbers, it's reimbursement is very crappy. The reimbursement for physical therapy in New York state is still $65, $70. You're not making money from it. At the same time though, my business partner and I have a local diagnostic company where we have eight full-time staff members exclusively doing diagnostic testing. This is where the major income comes for us right now.
That's amazing that you're willing to make that pivot. Considering who we're talking to, the independent practitioner, it would be really hard for you to make that pivot if you were in the situation, like a lot of physical therapy clinic owners, if you were treating full-time. There's no way you could have made those administrative decisions, those business decisions, if you were focused on patient treatment all of the time, I’m assuming.
Private practice owners do not value enough themselves and their time. A demonstration of that is the fact that they are spending all of their time doing treatments instead of doing any management. A private practice owner with a single PT practice who wants to expand and grow their practice must dedicate a minimum of two days a week exclusively on managing that practice. That is the only way that that person can grow the practice. If they just want to stay the way they are and just working as a PT in that clinic, then they don't have to do that. Somebody who wants to expand must spend a minimum of two days a week in business management. As you grow that time, they expand too.
That's my audience. Those are the people that we're talking to. They’re the ones that are looking to grow. If they want to stick around and just keep their one-practice clinic, that's fine, but they can always do it better. I'm targeting those that are looking to grow. Considering what you've gone through then over the past ten, fifteen years, what is your vision then for the future of physical therapy ownership? What do you see on the horizon? What positive and negative things do you see coming down the pipe?
The three top problems that physical therapists face right now are number one, reimbursement, number two, staffing and maintaining staff and number three, competition either from other physical therapy practices or competition from physician-owned physical therapy practices and from hospitals. These are the three major issues that PTs are facing in general. As a profession, when it pertains especially to a physical therapy, the single most important issue we are going to face is reimbursement or reduced reimbursement for physical therapy. Here is why I'm saying that. This is not an arbitrary thing or just a perception thing. There is data to back it up. What happened in January of 2007, Medicare changed how they pay for the initial evaluations. Now you have a three-tier code for initial evaluations instead of a single code, depending on the complexity of the problem.
They didn't change the reimbursement for each one of these codes. They pay the same. Why do they want to see that complexity? I believe very strongly that we are driven into a system of paid per visit, regardless of what you do. A flat rate per visit for Medicare regardless of what procedures you do based on the complexity of care, which means that if you're in your initial evaluation, you select a mild complexity, no matter what you do to that patient in the future, you are going to receive an x amount of money, let's say $50 for a sprain. No matter what you do to that patient, there is a moderate complexity or a severe complexity at different rates. I am suspecting that the most important issue and challenge we're going to face is that reimbursement issue as a profession. There is a solution and the solution is to expand as a profession our repertoire of services to patients.
Those physical therapists who are not looking at 2018 but they are looking at 2020 and beyond should be looking at other avenues and other things that they can incorporate parallel or in conjunction to their physical therapy services and practices so that they can expand not only the number of offices but expand operations in different services and diversify their incomes. They can bring in laser, they can bring in exercise programs, home exercise programs, gyms. They can bring equipment that they can sell to patients and materiel, nutrition and wellness, all those are things that they can do.
To do these things, they have to get trained on sales. They have to become good sales people because all of these things are cash based. On the other side, they can follow the route that I followed through HODS, Hands On Diagnostics Services, where you can incorporate diagnostic testing within your practice that pays five to ten times more compared to a single physical therapy visit. At the same time, it is insurance reimbursable. You don't have to sell to the patient to pay cash. This is where I see physical therapy, we have to expand our operations and our scope of practice so that we can be able to survive in a very difficult upcoming future in terms of reimbursements.
What really drew Will and I to HODS and the training in electro-diagnostics is that it was relatively easily incorporated into the current structure of our physical therapy clinics. We didn't have to add on a completely new square footage for gym space. We didn't have to bring on a nutritionist or learn ourselves in wellness practices or something like that. Simply we could add those services on as part of our physical therapy and completely within our scope of physical therapy practice, both with the diagnostic ultrasound and the EMGs.
I want to mention that EMGs is one of the major components. At the same time, musculoskeletal ultrasound can be a major component also. Evoked potentials, videonystagmography, VNG testing for patients with vertigo and even in patients who have hypertension and hypotension, autonomic nervous system testing is also something a physical therapist can be involved in. Physical therapists can be involved in doing Transcranial Doppler Testing as well as an electroencephalography testing. There is very large gamut of things that the physical therapist can be directly involved. Many of these will be directly reimbursed to a physical therapist. Others, the physical therapist will have to do them in conjunction with a physician or under the auspices of a physician.
There's been talk in the past about our ability to eventually perform and read x-rays. What are your thoughts on that? Just as a tangential discussion.
Actually, this is a fact at this point in a few states around the country. It is the position of the APTA that the physical therapist should be able to not only interpret and use, but also order imaging for patients who they treat. This is something that will happen, I believe, within the next few years.
I love your passion and your vision because it's completely applicable. We need to take a stand for those services that we can provide within our scope and not let them get away from one reason or another dude or groups that would rather us not be doing some of those services. It's important for us to take a stand and create a greater vision for what we can actually do.
If you don't mind, Nathan, I would like to plug in something else also in your program that on September 21 and 22, Friday and Saturday, HODS is going to sponsor a private practice summit in New York for private practitioners who would like to find out more about how they can grow their private practices, how they can incorporate a lot of these services. Also find out new tricks on how they can do their billing more efficiently, and so on and so forth. I don't know if I'm breaking the news to you on this, it will be hosted by your business partner, Will.
Then it's going to be great. I know it's going to be awesome. Thank you. If someone wanted to learn more about that summit, where would they go?
You addressed the reduced reimbursements as the issues facing PT owners. Let's move on to number two.
Staffing is an issue because of two main reasons. Reason number one, the number of available physical therapists in the country is much lesser than the demand for physical therapists. This issue was increased a couple of years ago when the immigration laws slightly changed in regards to specific professions including physical therapists. It is proper now to bring physical therapists from the Philippines, from India and other countries. The United States was the number one importer of physical therapists from India and the Philippines. This right now has changed. It is more challenging to do that.
That creates a lesser number of physical therapist available in the marketplace for them to be hired. There is a competition with higher salaries. Who is going to hire these people? Hospital organizations can afford much greater salaries that you as a private practitioner can afford. The second reason why it becomes more difficult to hold staff in a practice is because as reimbursement goes down, you have a lesser ability to pay staff bonuses and higher salaries as a private practitioner. No matter how much staff members love you and they have been with you forever, if somebody next door can offer them $15,000, $20,000 more per year, many people will take that offer.
They probably should. That goes to the point. Reimbursement rates are going down, the demand for physical therapist is going up, and so the salaries in turn go up.
There are three solutions I will give you about the staffing problem. Number one, create a team environment. People will look at the money, but number one, they will look at the way they get treated. If people are treated well, they are not going to start looking for another place to be hired.
The studies prove that money isn't the number one driver for people in their employment. If they can find something where they can align with the purpose of a company or feel like they're a part of something greater than themselves, or nowadays a lot of talk is about culture and how strong it is and I completely agree with that. If the culture is right, you have a team atmosphere working together for a single purpose and alignment that will override their demands for money many times.
As I said, three solutions. Solution one was exactly what we just said about team spirit, team culture, an environment that promotes growth. Number two solution, create a program where people can grow professionally by helping them with continuing education. This can have many different forms. You can seek continuing education from various organizations out there like Hands on Seminars or you can do in services within the organization, something that makes people feel that they are growing professionally. Number three is create an appropriate bonus system where people can be bonus for production. What we have seen a large number of HODS members around the country, because they make more money through diagnostics, they can afford to pay greater salaries and greater bonuses to those staff members who are involved in the diagnostic area. I'm going to give you a very specific example on that, Nathan.
I'm going to speak numbers now. When I hire in New York a physical therapist for my physical therapy practice, I pay somebody right out of school as a physical therapist somewhere in the neighborhood of about $65,000 to $70,000. If I hire somebody right out of school to work for my diagnostic business, I will provide them the entire training and I will start them at a salary of $85,000. That's the minimum salary that I pay. Later on, I ended up paying them much higher. They can reach to $100,000 to $120,000, and so on and so forth.
The salary itself is higher but the training that they're getting on top of that only makes their credentials greater, which allows them to earn more down the road.
That's about staffing.
Going back to the points number two and number three, one of the successful actions that my friends in California, Brandon and Richard, are doing at Coury & Buehler Physical Therapy, they shared with us was that they developed a mentorship program for their new grads. Between the staff of PTs that they had and they themselves, they had a specific mentorship program in which someone was assigned to each new grad that came in. They would spend weekends, I want to say one weekend a month over the course of a year or two, where they would dive into certain diagnoses or certain body parts as part of their mentorship program to help them learn and grow, coming straight out of school. They said that the hiring of new grads improved significantly based on that one action that they were able to provide mentorship. That rung true to a lot of the new grads coming out. The fact that you're doing that, and I've seen that also as social proof in Brandon and Richard case, is very powerful.
Number three, competition. Here is the point where if you want to expand, you cannot afford to be just a clinician. You have to become a real business owner where you are looking at expansion plants and you're looking at new, fresh ideas that you are going to bring and incorporate in the practice so that you can attract your community, so that you can attract even physicians sending you patients because you have something used, you have a niche. Whether you want to bring in a laser and promote laser or you want to bring women's health or you want to create the TMJ program, any type of niche that you can create that you can drive people into your facility.
The more people who come in for an event or for some reason, the more people will eventually stay for services. Incorporating diagnostics sets you thousands of miles ahead from the competition because simply not everybody can do that, not every single person can incorporate that in their practices. It requires a special person who can think about this very seriously and dedicate and committed to it. That can set you up way ahead from your competition in the area.
That's not just a physical therapy concept, that's a business concept. The more you can niche down and set yourself apart, the more you'll separate yourself from the competition, especially in physical therapy where I believe our services are becoming commoditized, to the point where you hear a number of patients I have and you may have as well, a number of people you come across might say, “Physical therapy didn't help me.” You don't say that about dentistry. You don't say, “Dentistry didn't help me.” You said, “So and so dentist didn't help me so I'm going to find another dentist.” We've been commoditized to the point where people will say, “Physical therapy didn't help me,” instead of saying, “That physical therapist doesn't know what they're doing or I didn't like my interactions with them.”
“I'm going to find another physical therapist that can help me.” Because of that, it's even more necessary that we niche out and do what we can. Plus, when you consider hospitals don't look at physical therapy as a profit center based on my experience with hospital executives. Usually it's a loss that they take on the books. They know that it's got to be part of their care and they've got to provide it to meet certain standards or requirements or whatnot. They are not looking at it to generate a significant profit so they can provide the physical therapy. We've got to do something different.
Nathan, when these patients go to the hospital for physical therapy, even if physical therapy doesn't make money for the hospital, these patients will get also their MRIs. They'll get these diagnostic test, that diagnostic test, in the hospital. They'll see other physicians in the hospital which creates then a regimen for the hospital. What I'm proposing here from a business aspect only, you have the audience already in your practice, you have the patients. By adding diagnostics on those patients, you are adding significant additional revenues for a captive audience that you already have in there. Simple as that.
Dimi, you've provided a ton of knowledge so far. It's great. Any incorporation of those concepts for any physical therapist would increase the value of their clinics and also improve their lives. The stuff that we talked about thus far have been great. If you were to go back and tell something to your younger self as a business owner, what advice would you give?
Go first to business school and then go to physical therapy.
Get some business acumen, get some business training, whatever that is.
In one or the other way, get early on. Get to learn business management administration, marketing, PR, because these are tools that can put you in a causative position over your business. You can make you more causes to make you to be able to achieve things in your business the way you want them instead of the effect of the troubles you have and the environment.
That's one reason why I have the slogans to step out, reach out and network. It is those steps that we take, either stepping out to reach out to a consultant, to read a different book, and then step out of your practice at a minimum of probably two days a week to do administrative tasks can be visionary for your clinic. Be looking ahead and working on your company instead of in your company, then networking and getting to know other physical therapists because a lot of them are going through the same issues. If we don't work on these things together, then we're going to just get run roughshod by the other segments of the healthcare professions that will take advantage of our inability to fight back.
What you're doing with this show and podcast is a great service to the physical therapy private practice community. That's really awesome.
What's in the near future for you over the next couple of years, Dimi? What are your big goals and plans?
We're still working with our consulting firms, Survival Strategies, through the years. We are in a program called Power of Choice. With that program, we are working in completely with what is called phasing to, meaning phasing out completely from three of our four businesses. Both my business partner and I want to be completely out from the PT business, the seminar business and our local diagnostic business.
When you say phasing out, you're not selling, you’re going to be passive?
Correct. Just having only a role in the management of the businesses where the businesses have been running very effectively at 110% every single day, every single week, every single month.
You're going to the Board of Directors level. That is great. Then what?
I have a tremendous passion about the HODS concept, the concept of creating an autonomous physical therapy industry, a physical therapist becoming an autonomous provider and becoming the provider of choice for the different diagnostic testing modalities. I want to dedicate most of my time and effort on that because I believe this can change the landscape of the entire physical therapy profession.
Dimi, if people want to get in touch with you, how do they do that?
A couple of things, first of all, DiagnosticsForPT.com is the website for the diagnostics. I have absolutely no problem sharing my cell phone number with everybody. I shared it in my emails. If somebody calls me or texts me, I do answer. It’s 917-538- 2242 or Dimi@HandsOnPT.org.
I would be surprised if you didn't get a few calls. Thank you so much for sharing, Dimi. The concepts that you shared were invaluable and timeless and a lot of people could learn from your expertise and advice in what you've gone through over the number of years. Let me also say thank you for your vision as it pertains to physical therapists and diagnostics. You're almost a lone voice out there but it’s a valuable voice for our profession, so I appreciate you.
Thank you so much for everything that you are doing every single day for our profession.
Thank you, Dimi.
Good luck with the podcast.
I appreciate it. Thank you.
Dr. Dimitrios Kostopoulos, DPT, MD, PhD, DSc, ECS is board certified in Clinical Electrophysiology with over 30 years of clinical experience. He has also MD, DPT, PhD and DSc degrees. There are fewer than 200 electrophysiology specialists worldwide who have achieved a Doctorate of Science Degree (DSc) in Clinical Electrophysiology Testing. Dr. Kostopoulos is one of them.
The doctor is a Clinical Affiliate Assistant Professor for Charles E. Schmidt College of Medicine at Florida Atlantic University. He is a past member of SACE (Specialization Academy of Content Experts) for the ABPTS examination board on electrophysiology, an elected member of the Nominating Committee of the Academy of Clinical Electrophysiology of APTA, and an adjunct faculty member of Springfield College.
He is the editor of the Diagnostic Section of the Journal of Bodywork and Movement Therapies, and the author or co-author of numerous books, articles and research papers related to his fields of expertise.