The importance of the front desk, and the experience that patients have there, can never be overestimated. Stacey Fitzsimmons of Account Matters, Inc. has witnessed this time and again through her work with PT clinics across the country. Considering that the patient's assessment of your clinic (and not the therapy you provide) could hinge on those interactions, you have to make sure that the person at the front desk fits the bill and gets properly trained. Having a natural people-person and problem-solver and someone who is positive, encouraging, and straightforward is essential. Far more than we give them credit for, they have a direct connection to the revenues of your company. Now the question remains, are they more important than the PT's in the back? It's worth considering. Follow today's episode as Stacey sits down with Nathan Shields to tell you.


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You Could Be Losing $100k's! Tips For Creating An Amazing Front Desk With Stacey Fitzsimmons

I have Stacey Fitzsimmons of Account Matters. She's been in the physical therapy space for decades. Thanks for coming on and joining us. I appreciate it. We're going to talk about some important stuff.

You're welcome. Thank you for having me. It's a pleasure to be here.

Tell us a little bit about you and Account Matters, what you have done in the physical therapy space here in the last couple of decades and what you're working on. What's gotten you to this point as we're speaking?

Account Matters has been around for a few decades. The original founder of this company is my partner, Diane McCutcheon. She has been in this business for more than two decades. I came on board in 2003 in a consulting manner specific to the PT/OT world. That's what Diane's background was and me coming on board with her, I followed suit. The difference between some other owners out there of billing companies and me personally, is I went into a physical therapy clinic and got hired and I've done every one of the jobs at the front desk, the billing and collecting. The only thing I haven't done myself is the actual treatment because I'm not a physical therapist. Everything that I've learned when I was on the job and then everything I've listened to from people through the years of consulting was how I formed my billing company, Account Matters.

I tried to take all of the complaints of what people hated. I didn't want to do that in my billing company because I keep hearing people complain. That's how we formed ourselves. Going back to the 2003 time, we were forming ourselves of not just a consulting company, but let's open up and give this industry what they need and that's all admin support. Front desk right through your collections getting your money in. That's what we did in this business is we started the billing company. We started adding on, we started training programs and it was all geared towards the front desk and billing department. We offer all of those services here at our company that we can certainly do for people but we took it one step further where if you don't want to outsource your billing and front desk, you don't have to.

We do have trained professionals here that will teach the right person on your side in your practice. For some of those things is I've always tried to set myself a little bit different. There's certainly a ton of billing companies out there. There are a lot of good ones as well as bad. I like to be a little different. I like to try to capture things that I'm not your typical billing company that only knows how to bill, push your payments and collect. I do understand the entire private practice section for physical and occupational therapy.

You initially started off as business consultants and have worked your way over to the billing side a little bit more, from what I remember. When you talk about the billing cycle, you're talking not just about the billing department, but you included the front desk in that. That's a misunderstanding that some physical therapy owners have is not recognizing how much the front desk impacts your collections.

That's where my passion comes in. I was in a lot of pain and couldn't walk. I couldn't work because I was always in pain. I went to a physical therapist. For the reason you become a physical therapist, I didn't become a therapist, but I can appreciate the gift that therapists have to get people pain-free and live their lives. I also understand that you went to school to do that. That's your gift. I don't have that gift. I don't want to touch a human in pain. My gift is business and figuring out how to make sure that what you're doing is going to get reimbursed. A physical therapist by nature, you will do anything for anyone. You love helping people or you wouldn't be in this business.

The only way you're going to continue seeing people is if your doors are open. Click To Tweet

If you have a private practice, it's hard for a therapist to remove the heart. It's hard for them to say, “I'm going to treat Stacey because I know she can't walk and I don't care if I get paid,” which I understand from a therapist. That's your heart. That's you saying, “I need to get Stacey better.” I look at it from you're valued and you won't be able to keep your doors open if you keep doing this for people. I understand it, not from you just have big hearts that you want to help. I'm taking it more like you do, but you should get paid for it because the only way you're going to continue seeing people is if your doors are open.

Is that how you train your front desk people and your billing people? Not to necessarily remove the heart, but training them from a perspective of, “We provide a valuable service and we deserve to get paid as much as possible for the service that we provide. That is your responsibility to ensure that the collections come through at 100% so that we can be reimbursed adequately, if not more so, for the services that we provide,” right?

Absolutely. The part where we're working with the front desk and why I keep bringing your front desk person is because, in my opinion, your front desk person is the most valuable person that you have working in private practice. The reason is they’re the first person to answer the first phone call from a patient. Nathan, you might be the best therapist on the planet. If I'm hurt and I'm calling your clinic, I'm not going to talk to you. I'm going to talk to your front desk person. If she or he is rude, they don't pick up the phone, they give me non-complete answers, I don’t know’s, I will most likely pick up the phone and go to the next person on my list. It makes good sense to bridge the gap between your therapists, therapy owners and the front desk that is typically, “We just need someone to sit in that seat.” It's a lot more than sitting someone in the seat.

If you have the right people, you, as the therapist, with your heart of gold, don't have to answer your patients about their bills and what's going on because you have people to take that hit for you. That’s where it's very important to get the right people at your front desk in your billing department. Those are the people that you, as the therapist, “I don't know what's going on with you. I don't do billing. Go see Stacey in the billing department. She can tell you what you need.” It takes you right out of the equation and it will help your practice to be viable and profitable versus I want to help someone because you are helping them but you should get paid for it.

A good front desk person is like gold. They can set the tone of the clinic. They are the customer service arm of your organization if you will. As you said, you could provide the best therapy on the planet but if they get a bad interaction with that front desk person, either coming in or going out, they're going to remember that more so than the care that you provided. They'll find somewhere else.

Back when we were doing the consulting, we used to travel around the country and we would assess a private practice. What our findings are. We would go through everything down to when I walked through your front door, is it clean? Some places are dirty and messy when you walk in and me as a patient coming in here, “This is dirty. I don't want to be laying on this equipment.” It's very important to think beyond, “I have the absolute best therapist in the world.” It's almost where I can appreciate it if you're going to open a practice, the first thing on your mind is getting therapists in there but it should be getting your admin staff and then adding the therapist. The therapist already knows what they're doing. They need a bench, a table and equipment. It's about your admin staff.

How do you find, recruit or hire the right person for the front desk? What are you looking for? How do you train owners to find the right person?

I like to find and ask people certain questions about where they came from. I don't care if someone came from the local coffee shop and they're coming in here applying for a job to be my biller. I want to know, at that coffee shop, give me one of your worst days where every time you turned around, there was a problem, and tell me what you did to fix the problems. I want to know what you did at your last job. What was the perfect job you had? Tell me the one thing that you did to make a difference in the company you worked for. I'm usually the one to ask not so much specific questions about the job you're trying to hire them for, but I want to know what you do in your jobs. If you’re a hard-working person, it doesn't matter what your job was. If you're a cashier, be the best cashier out there. If you're a therapist, be the best therapist. I'm always looking for the person to be the best of what they are. Not everybody has the education to be a therapist or a doctor. Some are truck drivers, and they're the best truck drivers out there.

PTO 136 | Front Desk
Front Desk: It makes good sense to bridge the gap between your therapists and therapy owners at the front desk.


What you're trying to key in on is to get the best front desk person. When they come into the interview unless it's COVID time and you have a mask on, are they smiling? Do they smile at you? If your patients are coming in, they're not coming in because they feel great. They're coming in because they don't feel good. Is someone going to greet them with a smile? “Hi, Stacey. It’s nice to see you. Hold on. We'll be right with you.” In the interview, how did they dress? They knew they were coming to an interview. Were they sloppy? Because they'll do that at your front desk. Again, we're not looking for models. We're looking for a clean-cut, for someone that can speak clearly, someone that can smile, make people feel happy, warm and welcomed. Typically, what I look for when I'm going for new candidates, it's not so much, “Do you have a degree and what's your experience?” It’s, “What can you bring to us? If we give you the right tools, will you learn and be able to do this job?”

It’s maybe more at the front desk than from physical therapists, but we often talk about soft skills. Skills that have to do with personal interaction, feeling other people out, and becoming a problem solver because we can teach the technical skills like how to call, verify insurance, how to collect the copay, here's the paperwork you need to fill out and here's how you do the EMR. Those are all hard technical skills. We can teach you that stuff, but you want someone who's inherently what we like to call high tone. Someone who is naturally happy and excitable. They don't have to rev themselves up to interact with individuals on a regular basis. They want to interact with people and get to know them.

They ask more questions. They’re involved. They know, just like the therapists know, all about the dog, the kid that's sick, and the husband that's hurting as well. They ask those questions. We like to look for people who are in a high tone. I liked the questions that you brought up about people's past experiences because it sounds like you're trying to figure out, number one, were they high producers in their previous jobs? Were they also problem solvers? There's so much that comes out of nowhere at the front desk that if those people are going to be productive, they've got to be able to solve their own problems with the best knowledge that they have without coming back to talk to the owner every day or every second about, “I've got this. What about that?”

In any private practice that I've been in, they are busy. You've got people coming, do they have a copay? We've got people leaving, do you want to schedule an appointment? We've got referrals and OCS we need to get because this one is coming in tomorrow. “We can't schedule an eval for the first visit because this therapist doesn't like that.” They are answering phones so you don't want to hire someone walking through the door, dragging the feet, and sloppy dressed. You’re like, “What's your five-year plan?” “I just want to have a good job.” You're not looking to better yourself. I always say, “I like the people that don't try to be better than anyone else. I like the people that try to be better than they were the day before.”

You want that energy, but again, you don't want someone coming and telling you their whole life story because that's what they're going to do when your patients come in. You don't like your patients listening to me saying, “I know. I felt awful and this is happening because.” They don't feel good. You want someone at your front desk, “How are you doing? It’s a great day. It's sunny out.” It's really important. You're looking for an ambassador of your company. You're looking for a professional person that you can train on the hard stuff like, “Here's a book. This is how you build. This is how you do that.” You're looking for more than that. You're looking for someone that's going to fit in and make your patients feel like, “I'm so glad I came here. Stacey was so nice when I walked in the door. She couldn't have made it any easier to do my paperwork.” That's what you're looking for.

Many people that are reading might be thinking, “I don't have that person,” or they're thinking, “I've had a lot of turnovers and I can't retain the people that I'm wanting.” What are your recommendations for such a position that can be a high turnover position?

We do have a turnover guide. It's a free download that everyone, if nothing else, get your free Turnover Guide. It's a Hopefully, you can read some things that will help you out right off the bat. It's not science. Sometimes, people leave for reasons we can't predict or out of the blue, your best person found the dream job down the street. That's always a tough one to swallow. If you don't give the right person the right tools to succeed, they're going to leave because if you find the right person and you stick them at the front desk to figure it out, they're looking for guidance, a leader, and they will leave you.

Once you do find the right person or if you're reading and you think, “I know that I have the right person. She just doesn't know what she's doing.” It's up to the owners. It's up to you to get out there and find the tools to give to them. We have all kinds of training programs here at Account Matters that we work with a lot of clients on basic data entry. How do you put a person complete into the software? What is it that you're looking for? How do you call and check on benefits? They should be done before you have the patient in for their email. If you hire the right person and they don't know any of this, you're going to lose a lot of money. They're set up to fail. If it's the right person, failure is not an option. They will leave and find a job with a leader that will give them the right tools.

The right people want to know their scorecard and what does a successful front desk person looks like. If you can't tell them, “Your job is to produce blank.” Most front desk it is, “Your job is to fill the schedules.” There might be some other iterations of that, but it’s essentially, “Keep the schedule full.” That's their job. If they can't tell you that, then you haven't trained them on their basic purpose and product. Their job is not necessarily to collect all the copays. That's a vital part of their job but their main job is to keep the schedule full. Number one, they need to know stuff like that. They need to know the statistics that you're going to judge them by. That's what I meant by the scorecard. Are they collecting 100% of the copays on the patients that are coming in? There should be benchmarks.

Your front desk person is the most valuable person that you have working in private practice. Click To Tweet

Right off the bat, “You're coming with us. In your first week, you won't be very fast. The second week, we want you to go from 5 new patients in the system to 10 new patients.” You know your businesses. If no one has a benchmark, they're going to do whatever they want. I've certainly learned my lessons in business as the years go by, “I gave them an open-ended window, how come they didn't do more?” I gave them an open-ended window and they did what they wanted. It's all about setting benchmarks in what is best for the company, not the individual people.

Are there certain benchmarks that you think are more important than others?

I do, especially when it comes to scheduling. The number one benchmark is to make sure that every new patient gets in your schedule within 24 to 48 hours. If they call on a Friday, it will be Monday. Because people are usually leaving a doctor’s office with like, “Go see a PT.” It's top of mind, “I'm hurting. I'm in pain. I can't walk. I'm going to call now.” “I can't get you in for two weeks.” You all know PT places are everywhere. They're going to call someone else. I would say a benchmark is a 24 to 48-hour window for any new patients coming in. They need to make sure they learn the schedule enough to leave those spots open and get your patients in.

The other one that you brought up that I'm very big on is the copay and patient money. I'm huge on that because the minute your patient is discharged, it dropped 60% of you collecting that money. They are out of sight, out of mind, “I'm not going back there again. I don't have the money. I'm not paying it. I wanted to spend it on something else.” It's very important to train your front desk person right away, “These are the reports from your software that you should be running every morning because this will tell you what you should be collecting. At the end of the day, did you meet that? Did you collect all of the money or did you not?”

My goal is always 100%. I almost find no one that can do 100% but if you keep it 100%, you will get the most you can get out of your front desk for collecting. Why aren't they collecting? Is it because they're asking the patients, “Do you want to pay?” If that's what they're saying, you want to train them to say, “How would you like to make your copay? Cash, check, or charge?” Not do you because if you say do you and you have a 21-year-old and it's a Friday, he's going to say, “No, I'll pay next week because I'm going out tonight.”

Have you found a way for owners or front desk people to keep credit cards on file and make that transaction easier for copays?

I would say it's a 50/50 out there with people wanting to do it and people not wanting to. It's all above board and you can. There is a form that does need to be filled out from the patient because the patient needs to give you the okay. I do recommend trying to get the patients to leave a credit card on file. If they know it's on file and they've signed for it, then you should have no problem every time they come in saying, “Hold on, Stacey. Let me finish running your card and give you a receipt.” It's not a question and you're not asking. It's, “You agreed every time you came in, I was going to run your card. When I see you, I'm running the card.” It's little tips like, “Don't ask.” They already gave you their okay so run it when they come out, “I’m running your credit card. Your receipt is coming up in one minute.”

I came across a coaching client who used COVID as a nice excuse to minimize that hand-to-hand transaction contact and transmission or whatnot like, “We're going hands-free as much as possible especially here at the front desk. What we'd like to do is keep your credit card on file. That way, we minimize that hand-to-hand transmission.”

That's perfect because everybody is in the same boat. No matter where you live, you can use that as your excuse. Everybody is dealing with COVID so that’s a good one.

PTO 136 | Front Desk
Front Desk: Not everything is going to be a winner, but you can't let your employee tell you it's going to fail without proving it's going to fail.


You could say an excuse. You could say, “According to our new COVID-19 guidelines, this is what we would like to do.” Make that part of simply how things go.

The other benchmark you may want to keep in mind is cancel and no-shows. If your front desk person doesn't know how to track them properly, you might think you have a lot more cancels and no-shows than you do. Make sure that your front desk person knows that if it's not a true cancel, they're deleting appointments rather canceling appointments because that's a benchmark you can set not only for your front desk, you can set that for your therapists. I like to go, “How many? Why are they canceling? What are the reasons?” If you have a cancel no-show policy that has a payment associated with it and if your front desk is collecting, less likely your person will keep canceling and no-show. Those are my top three benchmarks I always give to people.

The cancel and no-show rate seems to be a team attack. If you're below 90% arrival rate, the whole team has to be involved. One of my mentors has said in the past, “The patient will only take their therapy as seriously as the therapist takes it.” If someone cancels and on their follow up visit after that, no one says a thing at the front desk or the therapist about the cancellation, how important it was that missing that appointment sets back their care and the results they're going to get with physical therapy, then the patient is going to think, “I can cancel. It’s no big deal.”

Being a billing company, we've seen mostly every denial, especially in the work comp insurance companies. We've had a few companies come after us for certain clients because they're wondering why it's taking so long to get better. When we send all of the documentation, they know that they've canceled and no-showed so many times that they stopped paying. It’s not only you at the clinic that’s like, “Now I have a therapist that doesn't have an appointment.” You can tell the patient but sometimes, it comes to the insurance companies. If a twelve visit is the norm for whatever part of the body for this insurance company but you're more like the ‘80s going another month that you may get questioned. These insurance companies are going to be mad at you because you're not making it important enough to get the patient in there. You want the patients in there.

The front desk is so vital in that aspect because the therapists aren't answering the cancel call that comes in. They’re not on the phone. It's so important that the front desk understands exactly what we're talking about now and how not coming in for therapy is going to inhibit their progress in care and prolong their care. Also, it's imperative that the front desk also understands the purpose of the clinic and they buy into what physical therapy is all about. If they're casual and laissez-faire about physical therapy and patients coming to physical therapy, that's their attitude on the phone.

That's why people get away with it because they're calling your front desk. “Stacey, can you tell my therapist I can't make it.” “No problem. Goodbye.” If the therapist doesn't say anything, they're like, “I didn't have to talk to the therapist because I see him three days a week.” If you said, as therapists, “Stacey, you missed yesterday. That's the third no-show you've had or the third cancel. We're trying to get you better. I built this plan specifically for you. We want to get you better. If you need to cancel, maybe you could come in at a different time the same day.” If they're not saying anything and your front desk doesn't know, your front desk will keep taking the call, “I'll tell them.”

You need both of them to come together to say, “I took a call from Stacey. She canceled again. Do you want to talk to her? Do you want to say something on the next visit?” They should be working together. Typically in the PT private practice setting, there's always a wall built up in between the therapists and the front desk or your admin staff. I am one consultant that loves to go in with my big wrecking ball and break that wall because it's very important that they communicate for the scheduling and for the no-shows. I can't tell you how many therapists hate their front desk because they always schedule the new people for the last visit of the day. My answers are usually, “Have you told them?” “No, I didn't.”

If you don't talk to them, they don't know. You want to make sure in your practices that there's no wall being built and there's complete communication. That will help your cancel, no-shows and anything else that has to do with your patients because if your front desk doesn't feel that they are going to be undermined or not listen to, anything that comes up, they're going to run to the therapist and say, “I just saw Stacey in the hallway. She said XYZ or whatever.” If there's no bridge between the two sides, you're leaving each one open to not say anything and your patients are doing whatever they want.

For those owners out there that have a front desk person that they're questioning, “I don’t know if this is working out,” or they’re not fully satisfied, do you find that front desk personnel who has been there a long period of time, say a year or more, and then you try to implement this stuff, that it’s hard to teach an old dog new tricks? Is it hard to push in some of these benchmarks, products, and training into people who have been there for a while?

Make sure in your practices that there's no wall being built and there's complete communication. Click To Tweet

Yes sometimes and no sometimes. What I will say is this is where the owner has to be a true leader. I know you've been with me for a year. We're making changes. They're non-negotiable. I am the owner. This is how I want it done. This is how it's going to be done. When you do that, it goes pretty well. Your worker might be a little upset for a few days getting to know the new process.

They can’t control how they're going to respond.

You can't. You have to stick with what you say. What happens sometimes is this is how we're going to do it. The next week you check-in, “It didn't work. I know how to do it this way. I've been doing it this way for years.” If the owner says, “Okay, fine,” and walks away, you've not bettered your company at all. You're staying the same and you're probably missing things. There was a reason why you wanted to change something in the first place. If you stick to your guns and they will not change, they're not the right person. If you stick to your guns and they're like, “This stinks but I'm getting the hang of it.” The next week, “It's a little better. I still don't like it, but it's better.” The third week, “It's not that bad. I’ve figured it out.” That's how you would approach your people that have been there. As an owner, when you make that decision, don't go back on your decision. It's this way. Once you do it correctly, prove to me that it won't work and we'll change it again but I'm not for changing until you prove me wrong.

I liked a couple of things that you said there. Number one, the leader comes in and says, “This is how things are happening. This is the structure that we're going to use. These are the checklists that you're going to follow. In the morning and the evening, you're going to turn them in.” What you said inherently in there without saying it was that you were also following up on a routine basis. It's not like, “This is how we do things. Good luck. Go do it and tell me how it goes.” No. It’s, “This is how we're going to do things.” Follow up on a routine basis and say, “How did that go? Can you show me what you did? Did you follow the process? What did that look like? Here are the checklists that I expected out of you.” If you draw the line in the sand but then don't follow up, then the front desk will go back to the same thing.

I can give you great examples because you're all probably saying, “She just talked about me.” What I see is a front desk person that has had that job for years and they've always done things manual. I'm talking mostly about copays and they're recorded on an Excel spreadsheet and/or a paper form that you have to fill out or a paper receipt. It’s then put into your new updated software that tracks everything for you. It happens to everyone. I'll say, stop the manual systems. You have three systems for a copay. You have software. It's 2021. It works. Use your software, “I don't trust it.” If you do that, you will have discrepancies because you're doing something three times.

If you have a patient asking you a question and you only did 2 of the 3, you'll forget the third one, “How come my three balances don't match up?” The perfect example would be, “Stacey, we're stopping the written process. We don't need the written receipts. They're all on the computer.” If you’ve never checked back in with me and this has happened. I've checked a month later, “How's your front desk doing after the training?” I'll start asking questions. “We still have the written one.” “Why?” It is follow-up. You want to make sure, as the owner, to be a leader. They're going to follow you. “This is how it's done. Do it this way successfully for three months. If you still hate it and it's not working, we'll change it again.” You've got to stick to your guns. If it fails, it fails. Not everything is going to be a winner but you can't let your employee tell you it's going to fail without proving it's going to fail. It's all about the follow-up.

They're not running the ship. They're trying to and they shouldn't be. You need to take the helm. You talked about it and while I have you, I also want to ask you about this. The communication and the relationship between the front desk and the billing department can sometimes have some animosity. How do you help that? Fortunately, we got to a point where the front desk love the billers and the billers love the front desk. They worked very cohesively and they share data. They shared their evening reconciliation forms on a regular basis. They were able to talk back and forth. The billing department could train the front desk on certain items and all that kind of stuff. For people who don't have that type of relationship, where do you start in healing that animosity between front and billing departments?

The first thing is you have to set the company culture as you're a team. I am passionate about communication and being a team. In my company, we all have hybrid schedules. The new people haven't even met half of the other people that work here. I'm big on team-building events. It's important to close your place down periodically to have your entire staff and forcing them to work together. There are a million things on the internet that you can get for, “What should I do for team-building exercises?” Pair people up with people they normally don't work with. They don't like each other because of their positions at their job. If you get that out of the equation, chances are they will like each other.

I also have an army background and anybody that's been in the military, it's one big team. You're not singled out. The goal of the company is to have 100% collections at your front desk and have your cancel and no-show rate at 0%, if possible. It's the company goal. You can set individual goals for people, but you should be bringing your entire company together at least once a month for some type of meeting. More than just lunch to say, “Stacey at the front desk, what are some of your issues you're having when it comes to scheduling with the therapist?” That's the opportunity to get someone to say, “I think this one gets mad at me every day because of the evals but there was nothing available. I'm not sure what to do.”

PTO 136 | Front Desk
The Administrative Power Center: Front Desk Training Guide And Workbook For Rehab Private Practices

That's the opportunity for the therapist to say, “That's really easy. Whatever the answer is, this is what I would rather you do. Come to see me. I'll move another patient. Whatever the case is.” It's all about forcing them to talk to each other. What we've done in other practices through the years is we would help host that first real meeting and almost force them. I would be bringing up, “When you're scheduling, what do you have trouble with?” It gives the opportunity for everybody like, “Don't take this personally.” We have one company goal in mind and what is the company goal? Everyone should be working toward the company goal.

Your personal feelings are non-existent. This is work. After work, if you don't like someone, fine. If you want to go out with someone, fine, but during work, the company should be all the same vision. Where is the company going and what is the job? Have those meetings. Don't have a meeting just for your admin staff and the therapist. You should at least do one company meeting and make it almost mandatory. Who are your managers? They should be getting other people to talk, “Didn't you say last week you were mad about whatever?” Call people out on what they're saying to get them to talk. You'll find once the mouth starts opening, it all comes out. People are usually, “If you would have said this to me a week ago, I could have given you the answer. I would have told you don't book my schedule XYZ.”

It's all about communication. Communication is the number in any business. Communication is certainly key. To bridge the gap, I would strategically form meetings or events where you're forcing them to work together. As I said, chances are they're going to like each other. If you put them in an environment where they come in and they can see, “The wall is up. These are my people because the therapists are in the back.” That’s how they come on board. Your orientation for your new people whether it's therapists and/or admin staff, you should be taking your new person, “This is Joe. He's the new therapist.” “Hi, Joe. I do all the scheduling. If you don't like what I'm doing, come see me immediately.” That's when you set that. As your new people are coming on, make sure they meet. Everyone they are going to work with and open, “This is my job. If you see any problems, you come to talk to me. I'll help you out.” That will help tremendously to bridge the gap.

Going back and thinking about it, the billing person was a part of the front desk training process. It wasn't some office manager, the therapist training, or the front desk themselves. There was a portion of our onboarding and training where the billing person would get on the line or come in person and train the front desk person as well to know what was wanted and expected on the billing side. There was that clear communication and they understood, “She wants it this way and she likes it filled out that way because of this reason. That's what I'm going to make sure I do.”

It’s funny you say that because I have a billing company. We have billers that come in and that's all they do is billing. We have people that come in, they are payment posters and then we have collectors. They all know what each job is because what was happening early on in the billing company is you'd get complaints from one of them about, “The payment poster this and the biller this.” If you don't know what they're doing, you need to appreciate their position. It's the same thing in an office and this is where your big company meetings come in. The therapist might be like, “This is an easy job. You're sitting at the front desk.” They all think that.

If you said to Joe, the therapist out there, “Since you have a cancel, why don't you come to sit at the front desk for the next hour? Listen to me answer the phone. I'm taking a copay. I'm scheduling. I’m entering new data into the software. I got a call on a referral because this one just left.” If they don't appreciate or know what someone's job is, it's so much room for them to criticize about stuff they don't know. You're a front desk person. They're not going to be a therapist but they should go back and see what they're doing. What is it that Nathan does when he goes back there with the patient? Is he nice? How does he talk to the patient when he comes in?

It should be, “This is what the therapists do. Every time a patient leaves, this is what the documentation is. When they're complaining notes, ‘I hate doing notes,’ this is what they're doing.” Otherwise, a new front desk person can be like, “What's the big deal? Just write a note. Stacey came in and she feels better.” If you don't know what someone's job is, it's very easy to criticize and point the finger until you sit in their seat. Going back to what I first said, I've sat in every one of the admin seats in a PT private practice. I 100% appreciate whoever is at that front desk with ten arms trying to get the job done. I sat in the back and watched therapists. If we're going back decades, there was no documentation. It was all manual. “I can't read your writing. What are you doing? Why do you have to write so fast? You have to do the whole SOAP. There is a lot of notes.” It's all about trying to not teach someone, someone else's job but to let them know what the job is so they can appreciate what each other is doing.

As we're wrapping up here, is there anything else that you'd like to share that you might recommend owners consider as they're looking at their front desk personnel?

Going back on everything we've touched on is look at your benchmarks. Start coming up with what you want to do because when you make the decision to make your changes, stick to your guns. Even if it doesn't work out, prove that it doesn't work out. Don't give up on it. We did write a book and it happens to be all about the front desk to create your own front desk guide. Go to our website We have a link on there. There's a book on Amazon and it is tailored specifically for PT and OT private practice front desk.

Communication is the number in any business. Click To Tweet

This will help you write a workbook that you can say to every new person coming in, “This is how we answer the phone. Everybody answers the same way. This is how we schedule and do the cancel and no-shows.” Go to our website and check it out. My biggest thing with owners is appreciating every person that's in your business and getting them to appreciate everyone else's position in your business. It's a ship that needs to move together with nobody jumping off.

What's the name of the book?

The name of the book is The Administrative Power Center because that's what we developed. Under it, it's billing for rehab private practices. It's oddly enough hard to find on Amazon because if you type it in, it comes up with everything that does not say administrative power center. When you find it, we’re the only book called The Administrative Power Center. It's your revenue cycle that we've renamed, we'd beefed up, and we made it a little more fun for people to learn instead of looking at your typical revenue cycle.

I love that you hit on reminding the owners that if they're going to make changes, be certain and clear about it. Also, make sure you verbalize what your expectations are. Our arrival rate is 85%. Successful arrival rates are at 92%. Make sure that's the benchmark. That's what we're expecting. Our over-the-counter collections rate is 75%. I expect it to be 100%. This is what my expectation is. Be clear about those and put it in writing. That's part of the book that you're talking about is to create that workbook, put it in writing and that workbook ends up being, “This is how you get to 100% over-the-counter collections.”

It's your guide on how to run a front desk from A to Z. My partner, Diane, and I wrote it. We have close to 60 years of this particular business. Diane has only worked in PT/OT private practice as well as I. My final thought is to check the book out. It's a great tool for you that you can use for your entire company.

If people wanted to reach out to you or Account Matters, what would you recommend? How do they reach out to you?

There are two different ways. You can go to our website. You'll see a little Ask Dan A Question and you can click on there. There's an info box you can send anything to. If you want to email me, my email is and I will get back to you personally.

Thank you so much for sharing your wisdom and your years of experience in this space. You shared a ton of great value. Thank you so much for taking the time to come on.

You're welcome. Thank you.

Have a great day.

Important links: 

About Stacey Fitzsimmons

PTO 136 | Front DeskStacey Fitzsimmons is the President and COO of Account Matters Inc. Prior to Account Matters Stacey served in the US Army as a paratrooper and a mechanic in the 82nd Airborne Division and then owned and operated a sporting goods retail shop for several years. Stacey has 18 years of experience working with physical/occupational Therapy private practice owners across the country.

Stacey along with her business partner Diane McCutcheon, have recently written and published the book “The Administrative Power Center” to help educate the importance of the front desk position in a private practice setting. Stacey’s mission is to provide the tools and or services of outstanding administrative support to physical therapists nationwide, allowing them to get paid right the first time.

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PTO 48 | Marketing ROI


One of the primary concerns of many private practice owners is acquiring new patients. Breaking down all the process and costs that entails, Steve Stalzer, co-founder of 8150 Advisors, is back to help us as he finishes off this two-part interview on growing your own private practice. This time, Steve shares the ROIs of marketing - how to easily break down the monetary efficiency of our marketing efforts and what it actually costs to procure a new patient. This may take a bit of work, but Steve makes it all easy as he guides us with gathering the data and going through the assessments needed for the least amount of cost that can produce more patients. Grow your practice strategically and systematically. Follow Steve while he talks about having a solid foundation of established P&Ps, leadership, and finances of a company.


Listen to the podcast here:

Determining The ROI Of Your Marketing Efforts - Part I with Steve Stalzer of 8150 Advisors

My guest is Steve Stalzer. I had part two of my interview with Steve that came out and you might be saying, “Where's part one?” This is it. This is part one of my interview with Steve. I had some technical difficulties and so now we're releasing part one after part two. Nonetheless, I'm excited to have Steve on for both episodes and thankful for his willingness to do so. He is the Cofounder of 8150 Advisors, a PT consulting and coaching firm out of Vail, Colorado. He graduated from PT school at the University of South Dakota back in 1997. He eventually joined Proaxis Therapy in Vail in 2001 and eventually grew with the other owners, the four clinics that they had into 35 clinics across four states with a staff of over 200.

They did that through a combination of acquisitions, openings, freestanding clinics and also forming several health system partnerships with hospitals. They actually pioneered one of the earliest and largest sports and orthopedic residency programs in the United States where they hosted ten residents a year between Colorado and South Carolina. He has begun consulting with practice owners shortly after selling Proaxis Therapy in 2015, where they focus on growth, efficiency and succession planning. He also has degrees in organizational psychology, physical therapy and an MBA from the University of Colorado. I'm excited to bring on Steve because I noticed as articles and his presentations through Impact Magazine and PPS Conference. He did one about the ROI’s of marketing. It’s something that I don't think a lot of us as owners really consider is how much it costs for us to acquire new patients per patient. Also, what are we getting back in terms of what we're spending on our marketing budget?

We should nail these things down. It will take a little bit of work, but Steve makes it really easy. If we do that and use those simple formulas, we can then focus our money into those areas which are going to provide us greater patients for the least amount of cost, especially into opportunities that can produce more patients. We cover a few things. The thing I'm excited about as you can use this data then to strategically grow your practice by funneling more of the marketing money to more efficient and more effective marketing programs. Also, to help you grow your practices, either the one that you're in or now you have a pattern for developing a new practice. It’s great stuff. Let's get to the interview with Steve Stalzer.


This is part one of my discussion with Steve Stalzer of 8150 Advisors out of Vail, Colorado. Thanks again for coming with me, Steve. I apologize again for technical difficulties, but part two happened and now we're back to part one where we started. Thanks for coming.

Thanks for having me on.

I'm excited to bring you on and I don't think I shared this, but I saw a couple of articles that you've done in Impact magazine for PPS. This one in particular that we're going to talk about is in regards to strategic growth and specifically how to determine the ROI of our marketing efforts in order to determine our strategic growth patterns. I was interested in your article, so I reached out to you and you were kind enough to respond and finally were able to schedule this. Before we get into that a little bit, would you share your professional experience and what got you to the point where you are now?

I joined a private practice that I started buying into and was the bulk of my career back in 2001. I had practiced for about four or five years in a few different settings prior to that. I joined a group in Vail, Colorado. At the time we had four clinics and about a dozen therapists. It was three partners and myself. We were very opportunistic about growth. It was a great group. We had a phenomenal staff. We had some good physician relationships. Looking back on that stage, we grew as a result of taking advantage of the opportunities that were presented to us. It was opening new clinics when something arose or someone brought it to us or taking advantage of a marketing initiative because we picked up a flyer or a local agency came and talked to us. At the time, we had the four clinics and they were part of a hospital MSA.

One of the things that we were blessed with was at the time, Sean McEnroe and myself, we were probably about 30 at that time, but our founding partners were in their 60s. We were forced to a pretty early stage to look at succession planning and look at the value of our practice so that as those guys retired and exited, they could have the exit they wanted. We could continue to build the practice that we wanted too. That was critical for us because as we started to look at the value of our practice, it helped us focus on not just growing the revenue or even the profitability, but looking at what contributed to value, things like referral diversity, pair diversity and our position within the market. We eventually grew it to about 35 clinics. We have clinics in Colorado, the Carolinas and Georgia. A combination of some MSAs, a couple of joint ventures and quite a few freestanding clinics. We sold that in 2015 and started consulting shortly after that as an opportunity to share what I learned along the way, both mistakes and things that went well. It’s to help other owners hopefully build value in their practice at a faster rate than maybe what we did in some of our years.

PTO 48 | Marketing ROI
Marketing ROI: There are two things that often limit growth - your ability to recruit great staff and your ability to market and spread the word about what you're doing to generate more new patients.


You mentioned the diversity of referrals. In a small town like Vail, you leaned on a few number of referral resources to get those new patients in the door. I know we've talked about it a little bit on the importance of referral diversity. What did you see at that time that allowed you to maybe step back and say, “In order to improve the value of our company, this is what we need to do in terms of referral diversity?”

There are probably two things early on. One was we had a phenomenal relationship with an orthopedic group that did a lot of destination orthopedics. A lot of patients flew in. They would have surgery and stay for a week or two as well as the ski industry. Vail is unique. It's an anomaly in terms of the typical market that you would see in a town that size. In the mid-2000s, 80% of our referrals were coming from one orthopedic group. We were forced to look at that and how we diversify. The other part was we had a service agreement with a hospital in Vail. Most service agreements will have a 90 to 120 day out and therefore that can impact value when you're looking to exit the practice. That demonstrates a lot of transitional risk for a new buyer coming in. Those were two things that we are forced to look at pretty early. They were helpful in helping us understand that as we grew, we needed to address those things. Not just grow those areas but, address referral diversity and address the risk associated with the MSA at the same time.

When you were with the four clinics and then gradually expanding and growing and taking on more clinics, I'm sure you had to feel like you were a little stretched thin in terms of maintaining physician relationships and creating new relationships. You eventually had to turn that over to a marketing person in essence. Tell me a little bit about that.

As most owners at that stage, in particular, the two things that often limit growth are your ability to recruit great staff and your ability to market and spread the word about what you're doing to generate more new patients. Like most owners, we had a hard time giving those up thinking if those are the two most important things that were driving our practice, we needed to focus on those as owners. Two of the early positions that we hired, one was a recruiter. Her background was in HR and she was a solid recruiter. She streamlined that process for us. What we found was she made it much more efficient and we could focus on building the practice, training therapists, working on clinic director development. That was a key position.

We added a director of marketing/practice liaison and charged that team on it. We quickly grew that into a team with not just growing the referrals, but also diversifying referrals for us. We continued to maintain the relationships with the orthopods, but they're building relationships with family practice doctors and internal med. We found something very similar where they were actually more effective than we would have been because it was something we did at the end of the day or the end of the week when we had time versus it’s something that they did Monday to Friday, from sunup to sundown.

Market on the things that are growing and have growth trends. Click To Tweet

Emily Bagby who was one of our practices on for a long time and she does some work with us. It's been fun to help her and share that knowledge with other owners. We did a good job with physician relationships. We had that relationship started with a doctor but in terms of reaching out to new doctors and saying, “Give us a chance. Here's what we're doing now,” but also asking that doctor, “What can we do better to meet your needs?” We found that there were some people that were phenomenal at that and often, they weren't clinicians. That was a big part of building our practice as well.

I don't want to go down that road too far, but you had to have some mistakes along the way in hiring that right person to be your physician liaison. What advice can you give us?

At some point, we should definitely get Emily or Madison on to talk about that more. They were part of a talk that I did it at PPS on strategic growth. It was great to see the volume of questions that people had for those guys afterwards. It was the one position that we used a personality profile to hire. We didn't use that on therapists or on clinic directors, but we actually used Asher APQ, and it assesses outside sales aptitude. It's probably one of the larger assessments, especially in the sales industry.

What we found was we needed somebody that had a unique combination of confidence, humility and confidence to go talk to that new doctor person that they hadn't met and built that relationship. It’s a relationship-focused position, but also humility. Doctors don't always want to be told what they should do. They don't always receive it well if you're there to “educate them.” It was a position that we did have some trial and error and finding the right people, but when we did find that right person, it was like, “This is what we were looking for.” It was a matter of replicating that. That assessment definitely helped us find those right people in the future as well.

It's interesting because you shared with me the story that you presented at PPS about strategic growth, but anyone hardly came up to you and your friend other than say, “Thank you.” There was a line of people coming into to talk to Emily and what she presented on in terms of strategic growth.

PTO 48 | Marketing ROI
Marketing ROI: Growing your practice without a solid foundation is no different than trying to build another level on your house when the foundation is falling apart.


Kudos to her for touching on a topic and it didn't surprise me. We were talking about things that are very intuitive, but maybe owners haven't thought about them the way we presented them. It was pretty straightforward, whereas Emily was the third in line to talk, so she probably didn't have as much time. It touched on the fact that most owners are not natural born salespeople. It’s not just looking at what should those conversations look like and who should we hire, but how do we give that person the right amount of support and training and help develop their rotation.

What should that rotation look like? It's an area that probably a lot of practices have an opportunity to improve upon. There's a lot of PL’s out there. Emily has stayed very busy helping to coach them with a goal of optimizing that investment and their performance. Those little tricks, whether it's establishing the rotation or establishing the flow of conversations in that relationship building as well as implementing things like CRMs to be a tool to help that person be more successful. It was fun to see the number of questions for those guys.

It's important to stay in touch with your marketing person, whether you have one or not. I was talking to an office manager. She said after they got rid of their marketing person, they decided to stop all marketing all together so they can do what we're talking about here in the next little bit about how to determine the return on investment on some of their marketing efforts. They stopped so they could say, “We're going to start at a baseline and start from ground zero, then start implementing things one at a time and see what the returns are as we do these things little by little.” That might not be a recommended way of doing things. She shared her experience, but talk to us a little bit about determining the ROI on our marketing efforts.

Let's come back to that example and talk about another strategy for assessing that while you're continuing things. One comment before we start on ROI is that marketing is always fun and it's always part of a strategic plan, but it's definitely important to assess your foundation before you jump into growth. You've had some great podcasts on managing metrics and looking at financial performance. We touched on referral diversity. Most owners looking back would realize that if they started to grow their practice without a solid foundation, it's no different than trying to build another level on your house when the foundation is falling apart.

Assuming that you're doing all of those things well. You've got a good handle on your metrics, you're capturing your charges appropriately, you've got a good training program for staff, then the question becomes, “How do I grow what I'm doing and how do I expand on what I'm doing?” Looking at ROI is the first place that I like to start. This is straightforward, but let's say a new patient generates $1,000 in revenue over the course of that plan of care. It might be $100 a visit and they did ten visits or some other version of those numbers. $1,000 is the average ballpark or maybe even a little low. If you look at the average profitability, let’s use 15%. That means each new patient is generating $150 in revenue.

Sometimes the best way to grow your business is to buy another business. Click To Tweet

Most clinics that I've worked with and talked to probably are spending maybe in the neighborhood of $50 per new patient. 5% of their budget is spent on marketing, either directly or when they include their time and energy and the mileage and things like that. You spent $50 in marketing and you generated $150 in revenue. It's a 300% ROI. First of all, we don't often step back to realize that and be aware that that's probably the best investment we can make, investing and growing our own practice. That's looking at the cashflow side, not even looking at how likely is that patient to come back in the future and turn it into multiple visits, as well as what value is that building within the practice.

That part's interesting, but then you're left with the question of, “I've got this great ROI. Do I spend more?” If you go back to the owner that you were talking about, my recommendation would be not to make dramatic changes of shut everything down, but the next step I would recommend is looking at your customer acquisition cost by referral source. I've seen owners either try and look at too many different referral sources or not look at it at all. When I say a referral source, I'm talking about four to six big categories, physicians, past patients, internet search and then maybe look at advertising or outreach depending on where most of your patients are coming from.

You can look at the customer acquisition cost for each of those over the course of a year. This was in the article that you were referencing in Impact. If you look at those four to six buckets, let's say you generate a hundred new patients from physician referral and you spent $4,000 in marketing to physicians, that would be a $40 customer acquisition cost. To me, understanding that is helpful in those couple of areas. It's not that hard to do. It does manually require asking the patient not just what the script was, what physician was on the script, but how did they choose your practice. Why was it that they chose you over another clinic?

Looking at your marketing budget in those same categories. You need to know how many patients came from that category and how much did you spend marketing towards that category. That gives you a baseline to say, “For every hundred dollars I'm spending on pay-per-click, we're getting a new patient. For every $50 we're spending on physician marketing, we're getting a new patient,” and start to look at those against one another and understand. From that, you can do some quick math on what's your ROI for each of those as opposed to looking at what is it overall.

I'm sure it can be dependent upon the clinic, but do you start recommending them that as they figure out what takes the least amount of money to get the most number of patients that they start funding funneling a little bit more money in that direction? What is your recommendation after they figure out these numbers?

PTO 48 | Marketing ROI
Marketing ROI: Anything that's small but has good growth potential are those things that are worth feeding and worth experimenting with.


It's not stopping there. That's a good baseline in understanding it. If you understand where each one of those sits. Back to that example of a hundred new patients from physicians, you spent $4,000. It was a $40 customer acquisition cost. Next year I might look at that and say, “What if I invested a little bit more in that, whether that's time or whatever it might be?” Let me up it from $4,000 to $6,000 and then let me look at what the result is of that. If I increased my budget by 50%, did I increase my referrals by that same percentage? It's an ongoing process.

The question that I often get is which of those should I grow? Which of those should I maintain and which ones should I maybe not do at all, back to back to your example. This is some information and there are several references or several versions of it. Back in ‘87, a guy named Gary McCain published an article called Black Holes, Cash Pigs and Other Hospital Portfolio Analysis Problems. It's quite simple. My version of it is to look at the current volume and ask yourself, “Is that big or small?” You can do this if we stick with service lines, “Do physicians make up a big percentage of your volume, yes or no?”

Is the growth potential big or small? Does that tend to grow year after year or if you put more money into it, does it stay flat regardless? The third question is, is the profitability from that big or small, is it average or below average? From that, you put your answers into a quadrant, and you can start to look objectively in the same way we do with talking about evidence-based treatment. You're not looking at your marketing plan, and your marketing results and you're looking at the results of that and taking the subjectivity out of it. A quick example of that is something that has a good ROI, has a large volume and is growing. That would be classified as a shining star, depending on which version of this. Because it's growing, because it's big, that's where you're going to want to invest more of your marketing dollars. Sometimes we lose track of that, and you start to see people investing in programs that are small and don't have substantial growth potential. Maybe a therapist has an interest in a certain service line, but it's not super profitable.

Because it's someone's pet project, it starts to get more resources and more funding than if you looked at which services, which referral sources make sense to fund. It's a pretty simple process, but the concept is market in the things that are growing and have growth trends. The things that are large but aren't necessarily growing, those are still things you want to maintain. Personally, I wouldn't drop my marketing budget from that. I might decrease my marketing by 5% or 10% and see if I maintain the volume, but I wouldn't walk away from my marketing towards that sector just because it may be not growing, but it's still a substantial portion of my referrals.

Applying that formula, the same office manager I was talking to said she was surprised that they got some new patients via radio ads. She'd spend a few hundred dollars a month, maybe $200 to $400 a month to replace radio ads. I'd never done any radio ads, so I was intrigued by the story. She said they get one or two new patients a month simply by the radio ads and if we applied this formula, the size of the referral source in that particular instance is rather small. You get out the ad and there's one referral, maybe two per month. “Is there greater potential? Is that growing?” “Maybe.” “Is the property profitability big or small?” “It's pretty good.” It’s not great, but in a situation like that, according to the formula and what we're talking about here, you're not going to all of a sudden jump from $200 to $2,000 a month because you got that one person per month. Maybe you keep it where it is or maybe the fire bolts instead of cannon balls. Feed another $100 or $200 a month and see what happens. It's an ongoing process. It's a living thing like you're talking about.

While marketing is the fun part of a strategic plan, it's definitely important to assess your foundation before you jump into growth. Click To Tweet

All of those points are right on. Anything that's small but has good growth potential, those are things that are worth feeding, worth experimenting with. As long as you're tracking what you did and what was the result from it, that's the same thing we do with evidence-based treatment. We invest in a radio ad or whatever it might be. Look at the result of it and see how that compares to the $1,000 we could have invested in a different area. You're exactly right. Making small calculated adjustments, things that are low-risk, they're not super time intensive, assess the result of it. If you find that you're getting a phenomenal ROI on it, then next year you might want to say, “Let's double that or triple that.” Start out with small calculated amounts and assess the results of it.

I had a conversation on another episode regarding having the owners align their visions with their physical therapy teams, the PT’s themselves and making sure that both sides are getting met. Sometimes that comes along with physical therapists bringing up programs that they've got ideas about or things that they want to start. The beauty behind calculating the numbers like we're talking about and that you shared is that it brings some objectivity to the relative success of those programs. After instituting a program that the therapist believes in and is engaged in and want to support your therapists and their dreams, you can say, “We'll appoint this much money to the program. Let's follow it, track it, see how it goes and see if it's successful or not.” Even though they might be getting fulfillment out of that program or pet project that they have, if the numbers don't bear fruit, then you can say it's not working. Maybe we can tweak things here or there and see how it goes from there. It keeps some objectivity to it.

I know we talked about an example. I was launching a cash-pay golf program. One of the newer therapists is passionate about golf. When you looked at it, it generated a referral a month. The investment wasn't huge, but when you looked at the amount of time they spent on it, the investment in it, it was what Gary would call a mangy dog, which is low volume, low growth rate and low profitability. When you categorize it that way, it takes them a personal attachment to it. You analyze it and look at it and say, “That probably isn't where we want to spend more time and energy.”

If that therapist has passions in another area, it might be good to point them towards things that are going to be more fruitful. I like to have owners keep the 80/20 rule in mind. Look at what are the 20% of the things you could do that are generating 80% of your referrals. If you can grow those and do those well while maintaining referral diversity and making sure you're building your value at the same time and not generating a risk inadvertently. That can help you focus on the things that are going to be most effective for building that value.

I know you get this question asked a lot, but what are your thoughts on social media? Have you seen any social media campaigns that have turned a good ROI in terms of marketing strategy?

PTO 48 | Marketing ROI
Marketing ROI: We may not be smart enough to predict what's going to work in the market in terms of marketing, but we're all smart enough to track what we're doing and assess the results of it.


The key is if the clinic is doing a lot with social media or any area, whether they're spending a lot of time or energy into it, first of all, look at what is their CAC and what is their ROI on that. Every clinic and I know you've had some discussions even with owners themselves about their practice and where they're investing, it varies by market. It varies by clinic. It varies by that person's social media following. The big question with social media is, “Are you doing it to retarget people who have visited your website, which can be very effective?” Someone looked on your site, maybe they called, maybe they didn't, but then you use a retargeting ad to get back in front of that person. That can be an effective strategy.

You also see a lot of people use it as a way to engage past patients. The clients I've worked with, it generally hasn't fallen into their bigger pockets in terms of it’s driving a big percentage of referrals. Often, they like to stay in touch with their past patients and they feel like it's an okay way to do it. It's a low-cost way to do it. Generally, I haven't seen it be one of those that becomes a high-volume, high growth rate, high profitability. In the practices I've worked with, it tends to be lower volume, lower growth rate. Therefore, it’s not a major part of their future marketing strategy.

Social media does well when it comes to patient engagement, especially for those past patients that have been to your clinic. You can keep them abreast of, “This is what's going on. This is a new PT that we have on board. This is what we'd like to do in our spare time. This is our culture,” or however you want to call that. The one social media campaign that I have seen that's been successful in my interviews thus far is with Roy Rivera out of Houston. He simply sits down with every patient at their final visit and says, “How did things go? Did we achieve your goals? Will you do me a favor? Will you leave a good review with us on Google and/or Yelp?” They say yes, and then they leave.

Inevitably two or three days later, he'll send a personal email to them with the links to Google and Yelp. There's a low-cost way of pushing what you could call social media. I don't know where you put Google reviews and Yelp and in terms of social media, but that was one way he leveraged those things in a cost-effective way to become the number one search for physical therapy in the Houston area. That's a huge population. That's the one thing that I've seen with social media. A lot of people use social media more for patient engagement for past patients.

The key is to assess your efforts, what's working and have a system. As you try all those things, which one's most effective, not just in your market, but your strengths are going to play into that. It sounds like he has a great way of doing that. He probably has some very solid strengths in terms of the connection with that patient. He's playing to his strengths. Where I always hesitate to say, “This is what you should do,” because the key is knowing what's working in your market, what's driving your business. As you invest more in certain areas, you’re looking at the result of it. For every example that we say, “This doesn't tend to be successful or this one tends to be successful,” you're going to have people reading this that there are clinics a little different. Their strengths are a little different. Their marketing plan should adjust to it.

90% of the battle is identifying where your greatest opportunity is. Click To Tweet

The key to this whole presentation is to be strategic about what you're doing and not say, “This is working somewhere else. I got a postcard, a flyer and an email and I'm going to invest in that strategy.” If that is how you do your marketing, make sure that you're actually assessing what the result was from it so that as you go by and open your next clinic, you have a great database to say, “We're opening a new clinic.” What have the results been from the direct patient or radio advertising or social media so that when you need to generate an extra 500 referrals to fill that clinic up, you've got a good plan for how should you go about doing that? How much should you budget and where should you put that money?

I love that you put that caveat on there because if someone was going to take Roy's Google/Yelp idea and implement, the recommendation should be to go ahead and try it and see what the results are. Make sure that maybe you calendar it out, do it for a few weeks and see what happens and follow a trend. Like you expounded on it, once you start following these numbers and you see what works and what doesn't work, that's where the power comes in. You can use those things to drive growth for not only your individual practice but for future practices. I love that you put that spin on it because now you have a marketing plan. “When I do this and I put in this much money, I have a pretty good knowledge that it's going to work because it worked over here, but we're going to track it still.” Trust, but verify. I love the fact that you put that. You eventually develop a plan.

I've even worked with some owners where for them it's unrealistic to track where patients come from in all of their clinics all year. They might even do it for three months out of the year to get a sample size of what are they spending over the course of the year, where are the patients coming from? It’s no different than any research that we would do in physical therapy. You're typically working with the sample size and then you're looking at the results from that. The key to me is having a consistent process to assess it and then ideally on an annual basis, going back to those questions of is this strategy, is this referral source? Is it big or small? Is it growing or shrinking? Is it as profitable as other things they could be doing? If you grid that out, then it becomes a very quick part of your marketing plan and assessing what you did last year and have a better plan going into next year. I often tell the owners that I'm not smart enough to predict what's going to work in your market in terms of marketing, but we're all smart enough to track what we're doing and assess the results of it. It just takes a little bit of work to do that.

I don’t know if this is applicable to smaller practices, but those that are growing, at what stage do you see practices bringing on and marketing specialist or a director of marketing per se?

PTO 48 | Marketing ROI I had that discussion with a group. You made a comment on one of your podcasts about bringing on somebody who can take care of the stuff that you least like to do or it's draining to you. Whether that's a marketing director or an HR, it depends on your strengths. In general, I would say when a clinic is in that $2 million to $3 million range, it starts to make sense to have somebody that's dedicated. It depends on your goals for growth, your growth trends and where your referrals are coming from and if you're trying to build your physician referrals versus trying to build your past patient referrals.

There are a lot of variations in that answer. Some of the things like Strive and Keith that have automated some of that past patient engagement. Some of those things have been very effective and a lower cost than hiring a full-time person. We also see a lot of clinics and they might bring a practice liaison on fifteen to twenty hours a week. They often find a past patient that maybe is looking for part-time work and knows a little bit about the practice. It has the right personality and the right skills for that role. It doesn't have to be jumping into a full-time position before you're ready.

Like we were talking about before, it's smart to test things out, prove out that it's going to be effective. Typically, in the $5 million range, that's where you start to see a full-time director of marketing or a PL being more and more common. It depends on the competition in your market. I work with a couple of owners and I personally encourage them to work more on recruitment because recruiting a therapist might be a bigger barrier to their growth in comparison to patient volume. There’s a lot of variability in that.

I feel like we've covered a lot and still, we’re focused on ROI and customer acquisition costs in regards to marketing strategies. Anything else you want to share with us, Steve?

Hopefully, we covered those pretty well. John Dearing I know did a podcast with you already. There's a lot of acquisition activity happening in the industry, and you see a lot of people outside investing in clinics, private equity groups, building organizations. That's an opportunity that is probably out there but maybe less utilized. Owners don't always think about expanding by doing an acquisition. It was either John or one of his partners that once said when we were working with them, “Sometimes the best way to grow your business is to buy another business.”

That can definitely be effective for expanding your market share or if you're looking to enter new markets. It goes back to building your foundation and making sure you've got solid clinic metrics. Probably capitalizing on your marketing efforts, what's working and figuring out your market and then investing in it. Whether that's through some of the strategies that we talked about or potentially considering an acquisition. Those are all things that hopefully will help owners be a little bit more strategic about their growth. Hopefully, it will allow them to feel like they're making smart investments as opposed to spending dollars and not knowing whether they need to make that investment and not knowing what the result from that is.

Once established, Strategic Growth begins with knowing what it costs to acquire a new patient, and the ROI of your marketing efforts. Click To Tweet

I love that you shared that because the real power that comes from what we talked about, you mentioned it, but the importance of developing a firm foundation of your policies, procedures, your financials, your leadership team, the staff in place and whatnot. That puts you in a position now that you have that plus a real marketing strategy that you know works. Taking that to buying a practice and then implementing what you know is successful makes you powerful and make strategic growth, I want to say easy, but you start replicating yourself and seeing growth come from it.

It's about figuring out and understanding your own business, what's driving your own business and what drives results within your market. There is no marketing strategy for all owners. Once you understand that and understand that you can grow your business intentionally by investing in it, then the stage becomes more about investing in those strategies and starting to shift towards developing your leadership team and developing your clinic directors. Often when you get the marketing piece dialed in and you get recruitment dialed in, then your barrier to growth becomes more about developing and finding great clinic directors. As long as you know what stage you're in and what’s going to have the greatest impact on your value, 90% of the battle is identifying where your greatest opportunity is. At the same time, it's solving a barrier that exists for you now.

Thank you so much for sharing everything, Steve. If you have more to say, feel free, but make sure you share your contact information.

My email is Our website is They can find more information about myself. Robbie Leonard, who is one of my partners, does a lot of revenue cycle management and training in that area. Emily and Madison are both full-time consultants working with practice liaisons. Nicole Kluckhohn and all five of us were actually part of Proaxis and over time pulled that team back together. The band is back together, so to speak. They're a great group to work with. They helped us build our practice. I enjoy working with owners to help them grow theirs as well.

Are you going to be presenting at the next PPS Conference?

I got the acceptance. I’m doing a presentation on demystifying the valuation and sales process. In working with the owners or the past couple of years, we did several acquisitions ourselves. I went through the sales process yourself and have helped several owners out with both sides of that equation. You still hear a lot of misconceptions about understanding what drives value and some of those little details can be big details. Hopefully, it will help shed a little bit of light in that area.

Thank you for sharing everything and thanks again for joining me.

Thanks for having me on, Nathan.

Take care.

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About Steve Stalzer

PTO 48 | Marketing ROI Steve graduated from PT school at the University of South Dakota with a masters in physical therapy in 1997. After working in several leadership roles, he joined Proaxis Therapy in Vail, CO in 2001 where he was one of four partners in an outpatient practice that focused on sports medicine working closely with world renown surgeons at the Steadman Hawkins Clinic.
Over the next 15 years, they grew the practice from 4 clinics and 12 therapists to 35 clinics across 4 states with a staff of more than 200. Steve and his partners grew the practice through a combination of acquisitions, opening free standing clinics as well as forming several health system partnerships including both joint ventures and management agreements.
They pioneered one of the earliest and largest sports and orthopedic residency programs taking 10 residents each year between their CO and SC operations. They also collaborated with Blue Cross of South Carolina and Greenville Health System on a “Therapy First” initiative for the treatment of low back pain, and placed therapists in several ski town emergency rooms in Vail, Beaver Creek, Breckenridge and Keystone.
Steve attributes their success to having built a great leadership team and investing in that team by working with leading consultants both in and outside the therapy industry. Steve began consulting with practice owners to share his experience and knowledge with others shortly after he and his partners sold Proaxis Therapy in 2015. Steve is the founder of 8150 Advisors, a physical therapy consulting team that helps clinic owners with growth, efficiency, and succession planning.
Steve has degrees in Organizational Psychology and Physical Therapy from the University of South Dakota, and an MBA from the University of Colorado.
In 2018, he was the lead presenter on “Strategic Growth: Big Data, Cash Cows, and Mangy Dogs” at PPS along with John Dearing from Capstone Advisors and Emily Bagby, a Practice Liaison Consultant with 8150 Advisors. Steve has written several articles for Impact Magazine on Strategic Growth, Practice Valuation, and Succession Planning.


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PTO 47 | PT And Owner Relationship


Kim Rondina, DPT of Wisdom PT Coach, knows what it's like to develop leadership teams and build a thriving practice as she's done both successfully. However, as she coaches and trains PTs and their bosses, she is noticing that there can frequently be a gap between what the PT and owner are wanting from each other. What she notices is that if the owner, the leader, will take the time to really listen to their therapy team and tap into their strengths, dreams, creativity, and desire to succeed, they will get more out of their teams, work together to attain clinical and individual PT’s goals, and develop a team that is dedicated to the vision and mission of the owner. Creating that kind of environment can become a powerful purpose that drives growth, retention, and recruiting.


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Aligning The Mindsets Of Owners And Their PT Teams Equals Retention And Growth with Kim Rondina, DPT

On this episode, I have Kim Rondina of Scottsdale, Arizona, who I've known for many years since working together at a similar facility back in Arizona prior to owning our physical therapy clinics. One thing I know about Kim is she's truly a dedicated physical therapy professional. She’s an endless student and she’s continually seeking knowledge. She has an immense passion for physical therapy especially guiding therapists and accelerating their development and providing the coaching and guidance needed to do that. She is actively involved in teaching throughout numerous professional organizations now and has trained with as well as led study groups to enhance the skills of her local professional physical therapists.

She previously held positions of Director of Clinical Development and Director of Practice Performance for a fifteen-clinic outpatient private practice in Arizona and thus led their growth and development of hundreds of licensed physical therapy professionals and directors. She's engaged in such diverse coaching environments as one-on-one trainings with directors, roundtables, hands-on treat tanks and code treatments. She's also an owner of Transform Manual Physical Therapy which is a thriving cash-based practice without any marketing efforts. Her environment is very unique in that she treats clients on a monthly basis and has a three-month waiting list at any given time representing the raving fans that she's developed through her expert care. The cool thing about her is she provides not only expert care. She's an excellent private practice owner obviously and successful at doing that, but also has transformed herself into an excellent coach for not only the leadership teams but also the staff physical therapist to improve their manual skills.

I'm excited to bring Kim on. We cover stuff that really focuses on connecting the mindsets of PT owners and their therapy teams so that they can get on the same page. When you do that it can be powerful and beneficial for your company in terms of the environment you create, your retention of PT members, your recruitment of PT members and ultimately the growth, stability, freedom and profitability of your PT practice. Although it's something that has to do with culture in a sense, she shies away from that word, but I think it's all about creating an environment and a shared purpose. I'm talking too much. Let's get into the interview here and take a listen to what Kim has to say.


I've got Kim Rondina out of Scottsdale, Arizona. She has been a long-time peer of mine and is the Owner of Wisdom PT Coach. She's also a physical therapy clinic owner named Transform Manual Physical Therapy. Kim, thanks for coming on. We've known each other for a long time and we've had a hard time getting together on this interview. I'm just excited to put you on.

Thanks, Nathan. I'm grateful to be finally joining you and your readers. I wanted to thank you also for providing such a valuable resource for owners in various stages of their discovery and aspiration across being practice owners. It's definitely an appreciation in your direction as well.

Thank you. That's very nice of you. You know how all my podcast start. I want to know your story. In fact, I know a lot of your story because we've been around the same block down in Arizona but you've transformed since then and that's what really gets me excited about bringing you on, is to share with the community where you're at, at this point. Bring it back a little bit and share with us your story.

I had a similar beginning to most. It’s been a little bit of an interesting journey since then. I was exposed to PT as a high school in the intercollegiate athlete. It took me down the path of graduate school at USC where I got my DPT in 2001. Over the years, I worked in a variety of outpatient environments and grew into a role in which a great deal of my work was with leadership development, organizational culture, performance analytics and clinical excellence. I have a curious, analytical personality and over the course of my career, that's provided for some amazing learning experiences and opportunities both as a leader and a mentor. I definitely have a tendency to see things as many little labels outside the box but more importantly, my role is assimilating information to help people make better decisions and choices throughout their careers. A big part of that for me too is developing an appreciation for connecting with people where they're at in their journey. I appreciate this opportunity that you're providing to your readers and creating mindset shifts in how we can transform as therapy professionals doing so.

PTO 47 | PT And Owner Relationship
PT And Owner Relationship: Have the confidence to value yourselves and the services, and patients will respect that, but you do have to differentiate your service.


Just as you're going through what you're talking about, you've seen a ton of growth, and I've seen a lot of professional growth in you as we've come across each other over the years. You went from a traditional staff physical therapist to Clinic Director to being a big part or playing a large role in a large physical therapy group down in Arizona over many different departments. You were there for a number of years.

I was a therapist. When I first came out of school, I had a lot of ambition and ideas of what employment opportunities were going to provide me and I failed along the way because I had three jobs in four years. I never felt like I found a place that really connected with what was important to me, which was patient care, quality experience and outcomes for patients. I settled into a larger organization, a private practice down in the Scottsdale, Arizona area and was with that organization for ten years. I went from being a staff therapist to actually creating two jobs. The first of which was professional development, meaning there was an absence of mentorship within our four walls in our clinics.

Our directors had a lot of responsibility. At the time that I was with this organization, we had fifteen clinics and over 70 therapists. You can see the scale of operation wasn't a simple one but the absence of having time to commit to the growth of our therapists and our professional staff was definitely a need. We created some opportunities for that. That evolved into a little bit involving outcomes and performance analytics and looking at how our industry was changing and how to help our therapists be successful within those changes. It was a big part and that was an absolutely amazing learning experience and one which has shaped where I am now.

You were with that group for ten years but you all of a sudden decided to quit. Give us a snapshot of what that was like and what you've done since then.

It was definitely an unexpected moment in my life. I'm not much of a risk taker when it comes to traditional ways of doing things but on a Saturday, I decided that I needed to change my path and my course. I really didn't know what I was going to do but I just basically started to be curious and have an open mindset about what opportunities might lie in front of me. Eventually, not sooner after, I started to take on it a little bit of risk, and I opened a cash-based private practice in Scottsdale. I started that practice about three years ago. There were a lot of unknowns with that, a lot of scrambling to figure out what met the needs of me as an owner, my emphasis on clinical expertise and excellence and then obviously thriving as a financial entity as well. It took me about six months to have a full schedule. At this point, I'm proud to say I don't spend a penny on marketing. I bucked the trend. I don't spend a penny on marketing other than my initial website, and then I have about a two-month wait list. I'm focusing on my passion and my love for the highest level of care for the communities that we serve.

What gave you the confidence to not only break from this company that you've been with for many years but then also decided to go cash-based?

I think the confidence came from knowing that I did have some strong referral basis at the time that with my eighteen years of practice. I get my name on a script and I had worked with physicians over a period of time and I was able to provide a different level of care, service and outcome to our patients. I trusted that and went with it. On the cash-based side of things, I had some peers and I had started to do some training in a group that majority of the patients that had trained for this group were cashed-based. I built a network of individuals that could help steer me and give me guidance and direction and worked through those moments that you have and the things that you put up as walls or barriers. They helped me see through them and see the opportunity. I flipped the switch on the mindset and be curious about what could this look like.

The #1 Factor of Job Satisfaction: Good human relationships between boss and employee. Thus, aligning the mindsets of owners and their therapy teams will lead to growth as well as improved environments, retention, and recruiting efforts. Click To Tweet

You had some kind of coaching/consulting at about that time when you got started.

Informally, the more peer aspect of things. I have a few mentors that are more on the clinical side of things. One mentor is a little bit on the coaching side and probably less so on the formal side. My mentorship and consulting came from the growth and development within that organization that I was with for many years. It’s definitely a wide spectrum of exposure and understanding the variables that influenced my ability to be successful.

Kudos to you. That takes a tremendous amount of courage to not only step out on your own but also go against the grant and go cash-based. I know it's trending that direction in a lot of our clinics or companies but to do that right out the gate, it’s really impressive. That’s great.

It’s definitely an exciting opportunity. I worked with a lot of individuals now that goes through the same thing. “What gives you confidence? Why me? Is the patient going to be willing?” and all those questions. Unfortunately, it's prevalent in our industry, and I'm glad to see that it’s trending in the opposite direction and people have the confidence to value ourselves and value the services. Patients will respect that but you do have to differentiate your service. It's not just the status quo because our patients are discerning consumers and respecting that in what we offer for sure.

Imagine the audience was a bunch of guys who are considering going cash-based or are thinking about starting a clinic that is strictly cash-based. What kind of encouragement would you give them? What kind of feedback would you give them or things to consider?

Most importantly, be adaptable. You have to meet the needs of your consumer. When we come out of PT school, there's a paradigm in which we think that the application of our services in the scope of our work is what our patients seek, or referral sources were sent to us. In truth, I worked with a variety of practitioners that I never thought I would have relationships with, from people who work in the world of Reiki to Feldenkrais to acupuncture. These guys all create an opportunity to make a difference for a patient and it does differentiate. In the more traditional medical model, it is somewhat self-limiting based off of what directionality and who goes to what doctor, and are they seeing a primary or a specialist? Being adaptable means looking for potential opportunities for a patient's health and well-being regardless of the source. That's the adaptability there and having the confidence to do that and take on any patient that comes to you.

What other advice would you give somebody?

Secondly, you spoke to the confidence element of things. You've endured a lot to graduate with a doctorate level degree and your skill set is more valuable than you believe. We lack confidence when we're early graduates, but you'll find a way to be successful if it's important enough to you. That means you'll probably become more resourceful than you ever thought possible. That means you'll network in ways when you talk to people and think outside the box, having all the mindset and be curious. You start to take on a different role and identity when you're seeking to be able to have that autonomous and autonomous practice and freedom that we all seek in our profession.

Now that you are where you're at, looking back, maybe you’ve established this early on in your clinic ownership or even before you got there. There had to be an inner purpose that made you decide to quit on that Saturday. You eventually decided to open up your own place and go cash-based and work with these other types of medical health care practitioners. What was your purpose? What is your purpose now?

In that moment, it literally was a belief that our therapists deserve better and second and foremost, belief that our patients deserve better. I think we all can attest to some external forces that are influencing our industry between reimbursement issues with referrals, growing issue with retention and recruiting. It truly came down to providing interaction and an opportunity for a patient, for the first physical therapy business I have. It’s to make a difference in clinical excellence and demonstrate the level of which PT can make a difference in a patient's life. On the second side of things, our therapists deserved better and many times someone influenced us to be brave enough to take the leap into becoming an owner. Exploring our relationship with our decisions of becoming either an owner or a therapist with our expectations as either a leader or an employee really dictates our ability to have sustainable success across our careers. That to me is where we start to take control of our future and redefine and evolve where our practices and/or industry are going.

A lot of what you're working on now is either in your own clinic but also with the people that you're coaching. It’s helping them take control of their future and really define what they want to get out of life.

I mentioned that one coach/mentor of mine. She once told me that the best way to get the attention of physical therapists and especially owners is to appeal to pain. There's a little irony in being a physical therapist and saying that but definitely my experience has proven her recommendation accurate many times over. Some of our pain points as owners both internal and external, within our four walls as organizations or businesses, I call them the four Rs. The top challenges for practice owners we're all dealing with, I briefly mentioned that reimbursement. We also have issues with referrals, our retention of employees especially our A players and then recruiting, being able to bring those A players into our organization. I was flipping through some stuff. We transitioned to an entry-level doctorate in the early 2000s. I saw an article published in PT in Motion in April 2018 that was surprising.

For an eleven-year period of time, primary care physician referrals to PT dropped by 50%. Is our dependence or reliance on a referral basis really creating a thriving culture for therapists with that expectation of building a relationship with physician groups, the primary care or specialist space? The reimbursement goes without saying as far as the cost containment emphasis and the impact it's having on our relationship with payers and thus the cash-based environment that I choose to be a part of. Retention is a topic of conversation. I'm hoping it switches more to solutions. The student debt to salary ratio is exploding. There are lots of job hopping for financial gain, high turnover and burnout.

There was also a study demonstrating that from 2016 to 2017, PT saw the highest increase in turnover rate amongst all allied healthcare professions. We feel it, but when you start to see it in objective ways, it starts to magnify and create a focus on our need to maybe bring greater attention to our people, our therapist and our experience as professionals and employees. That's a little bit of a lot of the conversation that I have with aspiring young therapists as well as practice owners. Anybody who knows me knows that I like numbers. Another crazy statistic is the recruiting side, trying to find that player that fits our culture, fits our dynamic and fits our vision as a company.

What drives employee satisfaction is understanding their intentions and their purpose. Click To Tweet

First and foremost, PT is considered the third most difficult job to fill by a very well-respected human resource organization. The APTA also likes to always keep an eye on us and that our workforce and this one is going to blow you away. There's an expected shortage of over 26,000 therapists in the next couple of years. What's our role in that as business owners? Are we pushing people away? Are we eating our young in the sense of burning them out and having that high turnover and not getting them a quality experience as an employee? We're emphasizing it with our clients and with our referrals, but are we doing it with our own therapists that we're bringing in our organizations?

In your experience in the positions that you have with that large organization, this speaks back to your story in that one of your first roles then was the maturation and development of the professional skills of the PTs in your company. You also said on that one of your jobs was with leadership development. If you're really going to retain and keep people from burning out, I think it's a lot of those two things. Am I wrong? What do you think?

At a basic level of leadership development and definitely growing people, clinical expertise is there. The missing link that I hear commonly with the groups that I work within the practice owners that I touch base with is really connecting and relating to one another. The mindset of an owner, we all can respect the demands and what that looks like. The mindset of an owner has somewhat taken a step away from the mindset of a young therapist. This has very little to do about the generational dialogue that's out there.

The Millennial group has some attributes that create some demand for us to be nimble as employers, but they also create a really great opportunity for us to redefine our experience as an owner. Many times, they want and expect exactly the same thing we do. That comes down to purpose and environment. Many of us started a practice basically saying, “I want to be able to treat patients in this certain fashion or I want to be able to provide an environment that allows me to do X.” That's no different than the employees that we're hiring. Here's a little bit of a hard truth. The number one reason employees quit, what's your experience, Nathan?

When they quit, it's usually a better-paying job or malalignment. It just isn't fitting.

It definitely impacts their decisions but here's the truth. The number one reasons employees quit is their boss. People will leave a job not because they don't like their work or because they found a better position but because they don't like their boss.

When you say boss, that doesn't necessarily have to be the owner. It could be just their superior or who they refer to.

PTO 47 | PT And Owner Relationship
PT And Owner Relationship: People will leave a job not because they don't like their work or because they found a better position but because they don't like their boss.


Absolutely but in essence, the owner is still responsible for creating the culture and the expectation of whoever that supervisor relationship is with. The main issue and this alludes to what you were speaking to about why people leave is they don't have a sense of belonging. They can't really relate to what they're being asked to do on a daily basis. A study by Kota in 2018, they looked at job satisfaction in PTs and the number one influence of job satisfaction is better human relations. This gets back to, are we connecting with other people and are we creating a culture that enhances their experience as a therapist? Are we creating a culture of business? If you want to make a difference in recruiting, retention and our ability to thrive as practice owners, we have to ask some hard questions about what we're creating. Those drivers of satisfaction are purpose and environment.

That purpose is what motivates and drives us. We want to connect and relate and as business owners, we can say that's why we started what we're doing. The other element is the environment and this is the experience they have as your employee. The caveat there I'm going to say is there are a lot of times that people go through a checklist of everything they need to do in an organization from a mission to a vision statement to core values, review the checklist of onboarding. That's all great, but it has to be a non-arbitrary engagement. It needs to be genuine. Do you help your employee fulfill their aspirations as a therapist or are they simply a widget within your system that you've built? For me, that's the second aspect of my growth and maturation as a contributor to the therapy profession is to help bridge the gap between the mindset of an owner and the mindset of a therapist. We can stop dealing with some of the things that are potentially internally mediated and driven into some challenges that we have as practice owners.

Pulling back the curtain a little bit. What would you recommend owners do to step back and see if they are connecting with the therapist that they have on staff? What could they do to connect better with the therapist that they work with?

First and foremost, we have to focus inward. I mentioned some of the external things that influence our industry but lots of times as an owner, the first thing we need to do is focusing on ourselves. We need to get clear with our motivations and our intentions. We have to live them, and we have to grow our perspective as far as what our role and our responsibility is. We can't keep getting distracted by the parts of doing our business because we're always chasing. There's always not enough. There's not enough time. There are not enough therapists. There are not enough clinics. There are not enough referrals. There's not enough in the budget. That scarcity mindset really has to be washed out of our mindset as an owner.

Would you recommend they get clear on the company's purpose and then just try to start discussions either in staff meetings or one-on-ones with them and really communicating?

Yes, but no. I'm going to take a step back to that inward on ourselves side of things. Many times, owners will put language to their motivations in objective terms or in material things that they want to accomplish. They really have to get a sense of what they want to feel in their experience as an owner because that will dictate the what of how they approach their employee base and their therapist. If you make it about numbers, many times therapist resist that. If your meaning is, “I want to hit a certain profit margin,” or “I want to grow or create this goal and I want to have this many more new patients in the next six months,” or “I want to add to clinics,” the truth of the matter is it all comes down to what someone hears as more and the never enough and that mindset of scarcity. It’s switching the gears and getting a sense of what you want to feel.

If that profit margin or those goals give you stability and a sense that you're on the right path, those are the type of language skills and the direction of how you engage with your employee. One of the things that I commonly have practice owners, younger therapists go through is I’d have them spend three minutes and I basically say, “Write out your 25 most important wants in life and it's just free for all.” Majority of the time when you get to the end and you ask them, 90% of the things they write out are all material things or data-based like, “Here's a goal,” but it doesn't connect and relate to your experience and experience is a feeling.

The number one reasons employees quit is their boss. Click To Tweet

That relationship that we have with why each of the things that we have a conversation with our employee is important. Let it be a meeting or a performance review or simply having a connection with them. How's your day going? What's making a difference for you and that 360 feedback? There are endless possibilities but it literally comes back to, what is the feeling that you want to have and the experience that you want to have as an owner? How do you bring that into the relationship that you have with your employees?

When you're talking about these things, you haven't used the word culture, but that's what's talking to me.

Buzz words happen. That was part of my responsibility in my prior position. I think culture becomes a concept and it doesn't become the context in which we relate to people. Our therapists, they hear that word and they think it's important to someone else. If you ask them what's important in their culture, they might not be able to answer it. If you ask them what's meaningful to them or what's important in their environment, that's a language that they can relate to and share an experience. For example, environmental aspects. We mentioned a younger generation of workforce, they challenge hierarchy and they don't like the status quo. At the same time, they're absolutely open to change.

The opportunity there is finding the mindset that's open and curious and trying to find and create opportunities to build your dreams together. It’s because you both have the expectation of having a fulfilled career, let it be as an owner or as an employee in coming to work every day, having that job satisfaction and excitement coming to work every day as much as you do driving home. There's always that re-grounding of a question. The how is left up to the creativity of each individual organization. For some people, that's a non-answer but for other people, it gives freedom. That freedom and that autonomy is what allows us to evolve away from the status quo of what hasn't worked over the generations of therapists and so forth. I'm a little bit of an older therapist, but we've got therapists that have been around a little longer than us and they talk about the good old days in the ‘80s. We know we're not going back there.

We've seen a transformation of what influences what physical therapy practice and what physical therapy ownership looks like. Take responsibility for starting with ourselves. Create that intention of what that experience is when we walk in our four walls. How do you want to relate and encourage the people that have basically said, “Yes, you're the person I want to grow my profession with?” Meet their needs. In truth, when you find a willing partner, it's amazing the dynamic nature and the opportunities that will come of simply meeting them where they're at versus trying to get them to see things your way. Our human nature is people should see things our way.

Especially as the owner, you want to say, “These are the stresses that I'm dealing with. I don't know if I really care about your stresses all that much because if I don't make a profit, then both of us have a lot of stress on our head.”

In truth, the most genuine stakeholder we have in our practices are our therapists. It's not our payer sources. It's not a referral basis and it's not our community. Unfortunately, our community is still struggling to figure out who we are, what we do and finding us regardless of direct access and the work we've done in that arena. Our biggest stakeholder is our therapist. Don't look at your budget. Pull that guy out. Ask yourself, “Out of your budget, how much do you spend on marketing versus developing your greatest asset being your therapist?” More times than not people's marketing budget is greater because they're trying to deal with competition. They're trying to differentiate themselves. Now with social media and the ways that we have to get in front of people, it’s more of a financial commitment than ever on the budgeting side.

We also know that therapists on the average generate about three to four times their salary as revenue for your business. Doesn’t it make sense to basically create the investment in our therapists and their ability to maximize that top line revenue that they're generating year over year and create retention and satisfaction? Rather than some of the marketing money that we spend to the people that the entities have shown that they don't value our profession as much as we do. I know it's a scary proposition because we've spent decades focusing externally and giving external people power to define our success. That's not really how we're going to be fulfilled.

I'm just envisioning what it would take for an individual owner to really connect with the PTs that are on your staff and what that would mean. For me, you can correct me if you have a different opinion or idea, but it takes some one-on-one conversations where there is a truly vested interest in what that physical therapist wants and needs in the future. What you can provide them to help them meet their wants and needs as long as it doesn't sacrifice my wants and needs, then we'd come to an understanding. If I can provide you some of the wants and needs and even some of those dreams that you talked about on the top 25 dreams they have for life. If I could buy them experience, if they want to go to Italy for a week, what can it do as an owner to get you to Italy for a week? Is that the kind of stuff you're talking about and at least opening the dialogue between the owner and staff therapist?

I'm definitely coming to work for you if you're going to get me to Italy. That's one of my dreams, but yes.

If you kill it and you've got a two-month waiting list, I’ll send you anywhere you want.

To your point, absolutely. As practice owners, we have to be adaptable in understanding what our role and responsibility is. We can spend time doing, chasing, committing and going through the cycle of business of our professions. We all have those sour points of the things that frustrate us, and we feel like we're in an uphill battle against in the things that we feel like recycling old habits and old conversation points with our peers and so forth. You can get ingrained in that. I understand that, but that's usually the things that don't bring us joy and satisfaction. The aspect of our therapist team is they can relate to us as a therapist. When we sit down and say, “What is it that I can help you attain?”

Stepping back, someone committed to each one of us. We've had people that have influenced us. It might be in an informal way or a formal way where they sat down in front of us or dropped a little message that basically changed the way we saw our profession and how we can be successful and thrive. It's absolutely sitting down. I’ve built performance reviews. I've seen tons of different performance reviews over the years and they can be fantastic tools, but you have to ask yourself, “What is the therapist experience?” We've all had gone to reviews when we were therapists and for the most part, you feel like it's a process because it's a checklist. You have to go through it at the end.

It's basically usually connected as, “Am I getting a raise or not?” The intention there is I have to do this process as a leader or a supervisor. You're going to have the expectation but it doesn't mean that I get greater financial stability in the future. That's not long-term loyalty. As a business owner, you're not going to build loyalty off of that, and that's what we strive for because we want that stability. We want that ability to brand ourselves and have a familiar face for a doctor to refer to. Even if you have to go through an entire performance from you, you have to have an endpoint where it really comes down to the individual therapist.

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This is where the caveat is. Your leadership team has to have the time and the expectation of creating that level of engagement. It’s knowing their staff and truly committing to their future and not being fearful of them leaving, not being fearful of them becoming a competition. In truth, if we elevate each other and one another, the entire profession succeeds. Keeping people down is not working and trying to make sure that we keep our share of the areas in which we have our clinics and so forth. The truth is PT needs a lift up, not just a business or a region of the country. That comes from helping every new graduate and every employee that we have to really elevate the level of impact and growth that they seek to have.

The elevation, it seems like the trajectory of physical therapy in general because back in the day, a lot of it was about numbers, seeing your patients, being the better technician and improving your skill. I don't know if it's just a progression or if it's come with the generation of physical therapists and workers that are coming into the industry nowadays, but it's more than that. It's more of like, “I want to be in a place where I'm in alignment with their purpose,” or “I want to be a part of a group that's got a greater charity that they're involved with,” or “I align with these people because they've niched out into this specialty that I align with,” or “They've allowed me to create a niche within their practice that I really believe in and develop and hone my craft.” There seems to be more of that going on and less of the strict numbers because the numbers then take care of themselves as we invest in purpose and invest in the individuals, the therapy team.

Imagine if you’re changing how you approach your therapist and you start to discover what really motivates them and the gifts that they have to share and how they see themselves making an impact. All those things will start to open up the possibility of how your business grows, how it has different arms of the business, let it be we're going to reach out and do UroGyn or we're going to do CrossFit work or we're going to work with high schools. That comes organically within the people that you're having, but it only happens because they're driven by that meeting and that impact rather than a business owner saying, “Here, this is our next phase.” It's hard to pull people uphill.

The sense of belonging and going back to what drives satisfaction as an employee is the whole essence of everything is. It’s understanding their intentions and their purpose. Maybe this is my bias and my passion but hearing people's excitement about what they can do and what they can offer, my role at that moment is to be curious. It's to be open-minded. It's not to put my foot down and say, “Nope, that won't work. We've tried it before.” What future are we going to have or what type of employee relationship or employee culture are you going to have if they run into walls and you're that wall? Don't be the boss that creates the employee to quit.

Creating an environment like that just lends directly into two of the four hours that you're talking about, retention and recruiting. Your ability to retain at that point goes through the roof because these people have something that they're passionate about and recruiting means, they're not only doing what they love but they're spreading the word, “I work in a place that I really love to work at. You ought to join me.” You can show that to other therapists that you're recruiting. “This is what we're able to provide you. If you have a real passion for something, we can set you up for that.”

It is truly about nurturing and providing their ability to influence their future and your business. I'm sure you've interviewed dozens of people with a variety of different work environments. If we are paying attention around us not just necessarily our local communities but nationally, we see who's making a difference. We see who has raving fans of employees. You get a sense that there's freedom of exploration and there are a true curiosity and interest in how our business can be different, and that doesn't mean that everything has to look dynamically different than where you are now.

It just me not all clinics are going to look alike but it still comes down to your people and how you relate to them and giving them an opportunity rather than saying, “Here's the hierarchy. I've been here, I've done that. I built this. I'm the one with the risk and I know the numbers.” It’s giving an opportunity for someone to open your mind and shift your mindset and make a difference in your business because of retention. We get those A players, but we also squeeze hard to hold on but when we squeeze, we’re really not open. That's when we close off, get guarded and feel a threat and that's usually not when we're most dynamic, creative and adaptable.

PTO 47 | PT And Owner Relationship
PT And Owner Relationship: PT needs to be lifted up, and that comes from helping every new graduate and every employee to elevate the level of impact and growth that they seek to have.


When you say open, you have to really be open to the possibilities that you might not be able to be the best fit for that person. You want to try to create an environment where there's the ability to create and explore and do more but sometimes it’s just not a fit, and that's okay. I understand. How can I get you to the next place?

I have a peer that I worked with at my prior position, and she publicly admits that the best thing that ever happened to her was getting fired because she definitely wasn't a fit. There were a structure and an organization that focused on her weaknesses and dampened her creativity and the uniqueness. She was someone that is an amazing clinician, but it didn't fit into what the culture of the organization was ready for at that moment. She publicly admits, “I wasn't a right fit. I'm glad I got fired. It opened up this whole element.” That's just an example of sometimes the greatest gift that we can offer an employee is to admit we're not the right fit and there are all the sayings about the speed in which we hire and fire. We don't have to go into that. It's never easy to fire someone but in essence, you can do it with the right intention, and you can send the right message. You can still remain a resource for that individual across their career.

The benefit of that is it really speaks to you caring about that person enough to say, “This doesn't work for either of us.” When you're that vulnerable or that open and honest with each other or at least you come to that conclusion together, they’ll bend over backward to help you out. We had a guy that it just didn't fit. We were talking about the programs that we were doing, and we implement this, that and the other and he would improve for a while and then backslide and improve for a while and backslide. Finally, it got to a point where I was like, “Maybe this doesn't work for us,” and my business partner had an open and frank dialogue with him. We came to understand that it's time for us to part ways. I think he gave us two months’ notice and said, “Even if you bring them on, I'll stay around a couple more weeks to train them on what I'm doing.” It was great. It was wonderful and I know he's gone onto another group in town and they absolutely love him, and he's a great fit there. It just didn't work for us and so there's a benefit. I didn't want to go down to this is how to get rid of somebody. It goes to show that when you truly are open and honest with your team and looking out for what's best for them, that things can turn out the right way.

When I have a new graduate or a younger therapist coming and you're asking for career advice, the first thing I ask them is, “What are the top three things you look for in a career opportunity?” It's amazing to me that they can't answer it. When I say, “What are the top three things that you won't tolerate in a professional opportunity?” they know those things right there. They see the bad, and they avoid the bad but don't necessarily look for the right fit. As owners during our interview process or even with our team development side of things is identifying, “What are those three things that are important to you and are the things that we can honestly offer?”

We know the generation coming out right now, they all want mentorship and more learning. Do our business environments, our culture, our workflow and the demand of our day allow for true mentorship in the capacity that they're expecting? As owners, we all think that we're growing our people but what does that look like? Really working through what that expectation is because the last thing you want them to do is to feel that you're not committed to them as a professional because they've just spent over a hundred thousand dollars getting educated. They want you to help further that growth aspect. On the owner side of things, where does that get in our day?

Look for those opportunities, really finding and discovering through conversations, through networking, through seeking people within your own organization that are willing, able and interested to do something that you haven't done before. Allow for it to happen. Sometimes it's okay to try something and get surprised when it actually exceeds your expectation. Sometimes as owners, we always have that cautious tendency where we crawl into things and hope it works out right or we've put up a barrier before because we just don't think it's going to work. Allow yourself to try things and be amazingly surprised at how they thrive and grow organically within your organization.

Is there anything more you want to add? How can people get in touch with you? What speaks to you?

If we elevate each other and one another, the entire profession succeeds. Click To Tweet

As a message of the day, focus inward. As hard as it is not to allow all those external influences on us, encouraging in a culture and society that we have where there's so much business and chaos. Focus inward, ground yourself, get clear on your intentions, live them every day and grow through a perspective. That inward reflection also speaks to who you are as a therapist. Bring that focus on your clinical team, nurture them, influence their professional future and that is going to be vital to your fulfillment as an owner. In doing this, we're going to have an amazing ability to evolve the industry by committing to the people that are true stakeholders and that's our therapists. If there's only one thing that you learn is really differentiating who makes a difference in our profession and in your practice success. Let it be understood that it does come from within those that have dedicated the time, the energy and the passion for serving others.

When you really commit to your therapy team, if you're able to help them achieve some of their visions, goals and aspirations, even the dreams and experiences that they have in life, they'll do whatever they can to make sure that company that they work for succeeds or that you're also achieving your goals at the same time. They take a vested interest in the company that provides them with such wonderful opportunities to thrive, succeed and achieve their dreams. They’ll do whatever it takes.

I'm excited to see it playing out, for sure. As far as getting in contact with me, I am on LinkedIn both under Kim Rondina and Wisdom PT Coach. I do a Monday morning reflection in there just to re-ground us into some amazing thoughts in life in general. Also, through my website, you can contact me through

Thanks for being with me, Kim. This is awesome. I really appreciate it.

Thanks, Nathan.

Important Links:

About Kim Rondina

PTO 47 | PT And Owner RelationshipKim is a dedicated professional, seeker of knowledge, and endless student. She earned a Doctorate of Physical Therapy from the University of Southern California. Her interests are wide-reaching from discovering skills that will further enhance the lives of her clients, to self-awareness and all things 'why we do what we do'.

She combines an immense passion for guiding therapists and accelerating the development of the highest quality skills in real-world clinical environments, with a style that encourages appreciation of the journey.

Kim is actively involved in teaching throughout numerous professional organizations that she has trained with as well as leading study groups to enhance the skills of local professionals.

Kim previously held the positions of Director of Clinical Development and Director of Practice Performance for a 15 clinic outpatient private practice and has lead the growth and development of hundreds of licensed physical therapist professionals and directors. Kim engaged in diverse coaching environments including a one-on-one with directors, round tables, hands-on 'treat tanks', and co-treatments.

Kim is also currently the Owner of Transform Manual Physical Therapy, PLLC, a thriving cash-based practice WITHOUT any marketing efforts. It offers a unique environment of treating clients on a monthly basis, yet having a 3-month wait list representing the RAVING FANS she has developed through the expert care that she provides and personal mastery skills she embodies.


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PTO 38 | New Clinic


Matt Esrick, DPT is a "long-time listener" and reached out to me regarding some of the content of the podcast. Matt's a new clinic owner (less than a year) and, although he has an MBA, he still has some issues that he has to deal with - marketing, building relationships with physicians, and establishing himself in a crowded marketplace. John Woolf, PT has been a recent guest. When I told him about Matt's situation, he asked if we could talk to Matt about some of his issues and just push "record." I thought, "Great idea!" Here is the recording of our conversation. Matt was willing to share a little about his practice and the issues he's having, and was kind enough to listen to the advice and feedback we were willing to provide. My challenge to you, the listener, while listening, consider how you would coach Matt. As you scale, you will need to coach others - directors, VPs, supervisors, PTs. Start developing your coaching ears and consider what you would do/say to help someone in Matt's situation as if he was your employee.


Listen to the podcast here:

New Clinic Case Study - Roundtable Discussion with Matt Esrick, DPT and John Woolf, PT

I've got John Woolf and Matt Esrick here joining me in a first for the Physical Therapy Owners Club, and that is a little bit of a round table discussion. Matt reached out to me and shared some thoughts regarding the podcast. I had done a recent interview with John Woolf. I thought we’d put a few of you guys together and talk about the state of physical therapy and where Matt is in his practice. I'll let him share a story and maybe some of John's ideas on CSM. Matt, do you mind going first and telling us a little bit about your story, where you came from and what you're doing now as a PT?

I graduated from therapy school in 2016 after a career in consulting. That was successful but the economy wasn't at that time. We had a lot of negative business. We were on the darker side of things, whether it's axing jobs or trying to find cost-cutting approaches. I'm sick of it so I decided to just go back to PT school. I started working for a couple of doctors. I decided there was a better way to do PT. I decided to open my own practice. That started in September of this year. We finished our first quarter of business.

I reached out to Nathan after being a long-time listener of the podcast. I had some questions. I wanted to bounce some ideas and some opinions off of him and see what he said. That's how I got here. The actual backstory on our practice would be like a whole episode in itself because it's very convoluted. I know how to start a business. I've started businesses. It's one of those scenarios where a guy who has an MBA sit there and be like, "Why would you do practice in this scenario when you know better?" but you’re like, "I'm taking the ball and I'm going." That's what I did. We're growing but there's always those waxing waning moments of positivity and negativity as an owner.

Tell me a little bit about your practice. I'm assuming you’re an outpatient ortho. Tell me about your situation where you were at in New York, what those environments are like, why you chose that place where you're at and why you chose to do what you're doing.

We are outpatient ortho and vestibular. We're in Smithtown, New York. If you're familiar with the Long Island area, you already know we're all over caffeinated and generally angry most of the time, whether it's patient in pain or traffic. I work in a multidisciplinary office where we're all unaffiliated with each other. There's a physiatrist and a chiropractor in the same building. There was a medical marijuana weight loss guy, but he has since left. There's a men's health person. There's even an aesthetician. There's myself, the PT.

Did they invite you into the group or is this something that you founded?

That's where it gets convoluted. When I graduated, my first job out was working for the physiatrist and the doctor. We're going to start a PT practice together. That did not work out after talking to them because they weren't up to date on how physical therapy legally works, not that they were trying to do something illegal as much as they had an operational setup in mind that wouldn't work. I rectified that. I ended up working for the physiatrist for about a year. Like most doctors, I know and I'm related to, he’s a great doctor but terrible businessman. He wasn't our lead referral source for the entire year I worked for him, which is in a very irregular setup in a pop.

I kept staying on for a long time, working part-time in other places and stuff. I took a lead therapy role at other places part-time. At the end of March, he comes up to me and he's like, "I don't want to be in the PT business anymore." I'm like, "Okay." He's like, "Do you want to take over?" I'm like, "Sure. That's what I've been doing in a way. How quickly do you want to transition?” He was like, "How's two weeks?" I was like, "Are you serious?" He was very serious.

Literally April Fool's Day, 2018, it's over. It's not even two weeks. I'm like, "I’ve got to hustle to get all my paperwork in New York. I don't know how other states are but in New York to get a PLLC, it's supposed to take three months. It took until September, so you can't get an IRS number, which means you can't be in insurance as a group or anything like that until you have your PLLC. I'm in this awkward hold pattern where my finances are not in a happy place. We're still battling it out with certain insurance company registrations just like them closing that works and stuff. Now we're official as of September, but I've been at this technically since April. We're talking about volumes too, where I could have gone home for the next day and it wouldn't have mattered.

PTO 38 | New Clinic
New Clinic: As an owner, there's always those waxing and waning moments of positivity and negativity.


Now, I’ve got about 20 to 25 patients a week on average. I work a three-and-a-half-day week. It's one-on-one, which is a dinosaur in a lot of ways in the PT world, but I like being a zebra. It's simple equipment. There's a lot of technology in terms of the home side of things. There's manual therapy obviously. I enjoy it. I have a higher quality of life because of the way I practice. I wish our practice would grow faster because if you know anything about New York, it's very competitive. I can very literally throw a football to my three nearest competitors who are well established, whether they have pokes in with doctors or they're part of a hospital system or whatever it is.

I'm assuming you're trying to get in network with most practices. You are not trying to be a zebra in terms of going out of network or stuff. Are you trying to niche yourself in a certain way that separates yourself from the others?

At least on the insurance side, yes and no. One of your prior guests used a term I like which was like the insurances are on good behavior. I like that a lot because it's very funny because I agree there are definitely insurances that I have no interest in dealing with prior experience regardless of what they pay. I'm like, "This isn't worth the time." We do quite a bit about a network, believe it or not. We do a lot of cash, too, by coincidence. It's not something I've been pushing. At least in our area, I don't know what it is, the health plans. Some people's copays are $75. It's honestly higher than our cash rate or half-hour visits. I'm like, "Paying cash rate is easier." They're like, "Let's do that." It's unlike any office I've ever been in and I'm not saying that because I own it. It’s just the way we've been trying to run it and that's the way it happened in a lot of ways.

That's the way you want it, I assume?

As long as it's positive, yeah.

When you say positive, positive energy or positive cashflow, or both?

I consider those the same thing.

John, anything you wanted to ask about Matt?

Nathan, you had a podcast here with a young guy who is starting practice and you have an old guy who's already grown to practice. What happens is when you put people who are starting out together with people who've done it already, including yourself, there's some good conversation in there. It's almost like the old guy talking to the young guy. The first observation is you started this whole gig with an MBA under your belt already?

Whether you can or you can't, you're right. - Henry Ford Click To Tweet

Yes, MBA in Information Assurance, which is a fancy way of saying a difficult form of auditing.

You have a pretty good sense of numbers, changes in numbers.

I track 62 different metrics. Excel is something second nature to me, so that helps a lot. Our HEP app, because I've been working with as a beta tester for like three or four years now, that company unveiled a massive back-end data tracking system. It's based in Australia. It's their own version of MIPS in a way but specifically the exercise. If we do scale up, I'll have the ability to also go across different practitioners, different templated programs, different individual exercises and diagnose disease and filter them out. I’ll be like, "Maybe the exercises aren’t so good with this population anymore.” We narrow it down that way. That's been pretty cool to see you can almost run your own research. I don't have time for that at the moment, but it's something I'm looking into.

Doesn't every business owner run their own research?

I would agree with that, but I don't think in that context.

It certainly gets different. At the same time, how many guys and girls out there who are owners looking at their data to inform them of the decisions that they're making?

I would hope everyone is, but I don't think that's true.

I don't think so either.

I don't think so either. That's where I have to compliment you, Matt. You look at me, I didn't have an MBA. You definitely have a leg up on most people.

I didn't have an MBA either.

It took me I don't know how many years to figure out what my P&L was and my cashflow and stuff like that. You've got a leg up for sure. You're ahead of the game simply because you're tracking your stats. That's huge. A lot of guys don't do it.

PTO 38 | New Clinic
New Clinic: The ultimate success is the degree to which you can establish successful relationships.


My concern isn't the tracking of the stat. Like you've said before, for tons of other people in business and books say if it's not measurable, it's not getting fixed. If it's not getting fixed then you're more or less screwed. The data itself, if you don't know what to do with it, then I don't think it matters. I have a lot of data on growth, on our marketing strategies, and things like that. It doesn't help when I'm dealing with a front desk person when I go to a doctor's office for some direct marketing. There's no way I'm getting past that front desk. It doesn't matter what data I have. I could come in with gold bars, I'm not going to get to talk to that doctor. It's not going to happen.

Doctors don't want gold bars. Maybe the doctors do, but I don't think the people at the front desk want a gold bar. You're talking about something different. It's not the hard science of numbers and data, but it's now the interpersonal side, the relational side of what makes a business tick. There's a ton of research now about how the impact of not just the intelligent side of your business but the emotional side of your business. This little bit of my wheelhouse after all these years is the ultimate success is the degree to which you can establish successful relationships. What you said is spot on. It's a real common case study. It's like how is it that you get past that front office lady to talk to the doctor? By the way, does it matter? Is the doctor themselves making the referrals or is it someone else? Can we bump into this topic? Is this a good one?

That's fine with me. Do you want to go into that a little bit, Matt?

Matt, what do you think? Do you want to bump into this one?

I've been in scenarios where the doctor has nothing to do with the referral. I've also been in a scenario where I've sat for 30-something-minutes with a doctor thinking this is going to be a great relationship and got nothing out of it, which aggravates me. It makes me question my own skills. I'm a pretty good negotiator most of the time.

Were you in there to negotiate with the doc?

He proposed something I expected, which I don't have a problem with, which is a very soft version of one hand scratches the other. “If I'm going to send you patients, they're a hip surgery, I'd like my name to come up.” I'm like, "Your name will come up if your outcomes dictate that, and they do which is why I'm sitting in your office. If you weren't a good surgeon, I wouldn't be here." He liked that, but I still see nothing from him. I look at our marketing numbers for direct to doctor marketing. I'm like, "I don't know if this is all worth it at this point because they all still have hooks in with different hospitals and surgery centers to do these surgeries." I don't think the referral is coming from the doctor anymore. As a result, I'm looking at different avenues to do marketing. It's a quandary of sorts.

It is a quandary. It sounds like you stepped back to try to develop a strategy for it.

Definitely, I'm disgustingly organized.

That's a compliment. To be disgustingly organized means that's cool. You need the most help trying to figure out back to 33 versus 53. Nathan, you're older still. We're going to throw your age numbers into the story, too. We're going to combine our efforts to answer some questions. If one specific executable thing were better so that it would support your objective to grow your business, what would it be?

If it's not measurable, it's not getting fixed. If it's not getting fixed then you're more or less screwed. Click To Tweet

I know it sounds like a broad question even though I know it's not.

There's no right answer. Let's shoot from the hip and say, "If I could figure out that front office lady to get back there."

I would say the biggest thing I face right now is I need to boost our social element both in a marketing sense and an awareness sense. Get our name out there. On a personal level, I hate social media. I hate it. It's very unmotivating to do it when you hate it. I wrote to Nathan in the past, too. I'm like, "I want to know what someone says about ROI on social media because technically, social media is about building relationships. I've heard what you've said, John, about relationship-centered care and I was like, "That's genius," but how does that translate in a business sense to these things? How do you measure a relationship?

How do you measure it in the social space or how do you measure it specifically in a business space? They're slightly different.

I would argue business space at least in the sense that you have your marketing campaign for social in that context.

Social in the context of social media is very data-driven. In other words, those who are doing it well are watching numbers at an incredible level to determine what hits, what doesn't, the degree to what content people like about what. The big black box is what do people want to see other than cats playing the piano, which we already know works? What content or what information can someone give in order to drive the volume of exposures in your specific market? That's only one. The next part is the business side. To what degree does that translate in sales? To what degree does that translate into what would be a process of going to your clinic to say, "I want to go see that guy because he said something smart on the Facebook thing." I'm like, "I want some of that. I want some hands-on of that."

It sounds like you're talking about the conversion factor.

It exactly is a conversion factor.

What I was asking though is you gave the example on the last podcast with Nathan about the questions you ask when you're first doing an eval about their experience and their vision for getting better. When you talk about conversion factors and put it in that context, what are you looking at? I can measure engagement all day long on, Facebook and Google and all that. I can get that as a measure of business and how my marketing is doing. To me, that's not building a relationship because there are tons of research out there that suggests that the more involved in social media you are, the worse your actual relationships are because you've moved away from beyond what society operates into how we naturally would dictate a relationship.

That makes sense to me. The social thing serves to funnel people into a relationship with you beyond the initial engagement of a social platform. Back to the thing I talked about last time, let's say they walk into your office. That's ultimately what you want. If they do, then the presumption is that they’re going to pay you for some value. As a physical therapist, you have a tremendous value opportunity for them. The degree to which they understand and appreciate that value much depends upon a multitude of factors that you're going to present to them. Part of what you're going to present to them is the experience. These are the environment. I'm going to say because I'm hot on this idea, it's going to be the degree to which you connect with them, the degree to which you hear their story. One way to measure this is if they walk out and they say something like, "No one's ever listened to me like this." You will have hit it at least to the warning track, if not out of the park.

PTO 38 | New Clinic
New Clinic: Establishing relationships through social media is a big value that not many in healthcare and the degree to which your competitors are doing.


I've heard that and I agree with it. That's value right there.

It's a big value that not many other in healthcare are doing. The degree to which your competitors are doing it is going to be a differentiator.

How do you measure that value though that you established? It's a carry after the first visit. Are you saying it’s the fact that they're coming back?

Yes. You have an initial engagement and your first visit is a process of connection, diagnosis and treatment planning. The degree to which this is a successful process depends in part on how well you sell that treatment plan to that person. If you say, “You've got a thing. You've had now subacromial bursitis. It's common. You're 44 years old. You have a Type 1 acromion. It's not bad, but it's something. You have poor scapular control. This is how long it usually takes in my experience in order to improve scapular control in order to alleviate the mechanical pressure on this thing so that you can get that chemistry squared away and start feeling better and get back to playing with your kids.” “It's going to take that long?” “Yes, maybe not that long but what I want you to do is I want you to schedule this number of appointments.

Part of what we're doing is we're teaching you how to use your shoulder blade again. That's almost like going to a piano teacher. How long does it take to learn a song on the piano? It takes a while. It's not right away. It takes some practice. What you would normally do is you'd go to a piano teacher and they teach you some stuff. When you come back here in ICU, I'm going to be teaching you new things each time so that you can continue to improve how you use that thing. At the end of the day, you're going to feel a lot better and you're going to get back to doing what you love to do.”

If you can have those kinds of conversations right off the bat, you're going to kill it. That should be a typical pattern for any of your initial evaluations, whether they're coming into consult with you or not. If you have those types of conversations, you're going to be ultimately more successful not only in gaining their business but also retaining that patient so that they fulfill their plan of care. You're painting the picture, especially with their goals in mind because I'm sure during that conversation you're going to be talking about what their goals are. Do they want to play with their kids again? Do they play the piano? I'd like to go back to the question. I don't know if there's an answer to it. Matt, I know you brought it up to me and John, maybe you have some insight into it. You brought it up, Matt, in that there's a question out there as to what your ROI is on social media.

To make that jump from a social media engagement to get them in the clinic, that conversion rate to get them to step foot in the door, I don't know if people have a lot of data on that. The only thing close to anything that I've found was in my interview with David Straight from E-rehab. He highly recommended that if you're going to do Google reviews, it takes a tipping point of somewhere around 30 positive reviews for yourself to show up more on the search engines, to have greater SEO. That's the only thing I found. Sometimes I got this nagging feeling in the back of my head that no matter how much time we spend on Facebook, LinkedIn, Instagram, I wonder exactly how much conversion that's going to be. What do you guys think?

That's always been my thing because you want to go the avenues into both of what you heard and how you would accept a recommendation for therapy. I've never been going on Twitter and be like, "Who's a good therapist?" That's never happened. I don't think that's ever going to happen. At least I hope it doesn't happen. Going back to the ROI part, though, you can obviously measure conversion factors, but it doesn't tell you conversion cost of that conversion. That's where my concern is on the ROI.

I've built social media campaigns before and they've been successful. If you're going grassroots, you definitely have to suck it up and accept that it's going to be a slow loveless process. Eventually, you'll get there and then you do your pay-to-play marketing side of it and you'll get it. At the end of the day, I'm like, "Is this worth it?" I listen to a bunch of different podcasts, read tons of books on stuff like this. They're all like, "You got to get on social media." I'm like, "I feel like this is one of those hot topics where everyone says it," but in a service-based industry, I don't know if there is gain. I know a lot of people disagree with me on that, and I haven't done a lot of it for myself in PT.

I looked at everyone else's efforts and I'm like, "Unless you have a set policy in place where all of your employees are posting, where they're all engaging in this in line with the vision or in line with whatever outreach you're doing or whatever, how is this getting you profit?” It's the same question I see with a lot of people going to all these crazy manual therapy skills classes. I'm like, "Does this make you any more money? Does anyone know what this is?" I'm against specialties to some degree for that reason because no one's ever done a specialty on different OCS can get someone better, faster than I can.

It's very unmotivating to do something when you hate it. Click To Tweet

You're hitting on some deep topics. I'm going to do a deep dive on it a little bit. The first is like the social media thing. I'm going to context in this concept that people reach out to social media to connect. I had heard the statistic some time ago. I can't back it up right now. I don't know how accurate it is now, but the number one way people get information about their health is on Facebook. I shook my head at that too and I was like, “Could that possibly be?”

It explains a lot actually.

That's what I'm saying. It's like it says people make emotional decisions based on relationships that they trust and strangely people are stuck inside their phones out there connected and I've got my thoughts about it, but it's a certain truth. That's the level of relationship with people. I believe that engender some level of like, "I'm willing to try something." I believe that a certain amount of exposure to someone's nervous system about a concept. We see this in our current political atmosphere where people are being exposed to interesting messages.

Your brain starts getting into this thing. With regards to the degree to which it has an ROI, it has a lot to do with the cost of doing it. You're right. If your system is big enough, your sister runs a marketing firm and she can do all the social posting because she likes you and you're a good brother. You can get some regular content exposed in a fairly low-cost process. From that point, I would say that you could, anyone could, for that matter, begin to track data to determine the degree to which there's a certain number of likes.

By the way, social media is a process by which we’re communicating something, whereas in the past you'd have to go rent a billboard or something to announce a thing or take an ad out in the paper. You could have a 30-minute lecture in whatever organization you have or in your clinic about shoulder pain, the ten top reasons people have shoulder pain, and the three secrets to making sure that it goes away. It's that stuff that starts spinning people's nervous systems to want to start punching buttons and go, “I want that.” Clickbait simply for me is an appreciation for how the system works.

Back to it, I still think social is a process. It's a first level of expectation that people are able to form and help them decide if they want to engage with you like truly engaged with you. Right now, the continuum for engagement is pretty robust, which means you'd love to get them in the door, so they swipe their cards so that they pay you for the service. The other is now various forms of online advice, some of that webinar in shoulder pain in my area. If you like the idea, come on. It's going to cost you twenty minutes in the comfort of your house or wherever you want to do it. I do sense this, Matt. It's not unlike a lot of other people. If you don't dig doing it, if there's a part of you that's like, "I hate that." You're not Gary Vaynerchuk, the guy who absolutely loves throwing down and talking about wine or whatever else. Not all of us are built that way.

I like your point there, John. I didn't even think about that. If you're not into social media and even if you're not involved in social media yourself, it might be a waste of time because it's going to be something that you put on the back burner when it's something that you know you should be doing, "No, you shouldn't be doing it." It's on your to-do list. It's never urgent that you post something and put content on social media. Maybe you're better spent putting energy into things that you enjoy doing when it comes to marketing, niching, and branding out. Get creative in that realm instead of forcing a square peg into a round hole. If you're not the one that's on social media yourself, why waste your time trying it and trying to find the ROI?

That's why I asked about the ROI because it's a matter of dedicating the time that I could be spending on either something that has a higher ROI or something I enjoy.

Maybe it's more fun to figure out a way to get past that front desk person. Maybe it's more fun to niche down on a neat program that you want to put out to the community and send flyers to a certain postal code or something like that. I love that you brought that up there at the end, John. Maybe it's a waste of time if that's not in your wheelhouse.

I've talked to so many practice owners who are older than me. It’s like that classic, "I'm confused by technology and social media. I'm going to hire a young kid to do this for me," which ultimately usually is not a good idea. I feel like I'm like an old guy in that sense. I don't like video chat, to be entirely honest with you. It's one of those things. The first time I've video chatted with my wife. I was like the old guy that didn't hold the phone right. I was facing the TV. My point is that they don't seem to use it. Not that they don't use it well when they do, but they're fine. I look at that. You look at all other examples of what a successful practice is. Some of them don't use it at all. I'm like, "How do I get to that?" In this day and age, I feel like you do have to adapt to it, which is again why I keep asking about the ROI of it.

PTO 38 | New Clinic
New Clinic: Social media may be something that you put on the back burner when it's something that you know you should be doing.


Let's drill into that though. How do you get to what?

That successful practice that has almost no social presence.

What defines a successful practice? Let's say you had a steady pipeline of patients. There's a lot of other stuff you got to do well, but if you have a steady stream of customers in any business.

That means you have a solid revenue stream. I would argue a successful practice is accomplishing whatever initial vision and mission of the company was. Obviously, it should be profitable because otherwise, you're not going to be in business.

No margin, no mission. How close are you to achieving that?

We broke even in our first month, believe it or not, that's because our overhead is so low. I used to own a gym at one point, so sourcing equipment wasn't a problem. It was basically taking stuff out of my house. My wife got an extra room out of that, so that worked out well for her.

It sounds like you're on your way to achieving your purpose. What I'm hearing you say is that a successful practice is accomplishing the purpose of the owner?

It is, but it's also your own personal goals on top of that if you are the practice, like a scenario like mine. I have no desire to own multiple locations, at least right now. I do have an idea for scalability that I would like to do in the near future. There's also an exit strategy that was in place on day one. That's a whole other discussion. When you talk about like what are you looking to accomplish, I would like to make more money than I've made working as a staff PT as an owner. I'm not at that point yet, which is disappointing. I'm also not putting in as many hours to clinical work as I was. I stratify my own salary, to be honest with myself. Clinically, I make a certain amount. When I'm doing administrative stuff, I make another amount. Sometimes I don't even pay myself for marketing because I'm the one who benefits from this. This is insane. It's like paying yourself to drive yourself to your doctor. It doesn't make any sense.

Matt, what do you want?

In terms of the business?

The more involved you are in social media, the worse your actual relationships are because you've moved away from how society operates. Click To Tweet


I would like it to be completely self-sufficient. I've heard Nathan say it before and I take it to heart until recently. He used to live or die by the schedule that time. I definitely feel that on a regular basis. Some of that is ironing out how we schedule. Like you had mentioned, John, or at least if I understood what you said, it’s taking that relationship and basically converting it to the plan of care when it comes to the schedule. We block the schedule, but I don't fully do a full six weeks in one go. Some people think that's a huge error, but the reality is a lot of my patients won't do it. They won't. There's hesitation there.

There's hesitation there?

On their part or it's like, "I’ve got way too many things going on. I can't do that." I would say that's another classic definition of a sales objection.

They can't commit to getting better completely.

They can. They might schedule two to three weeks out. I've got to schedule six. Sometimes it's like, “I'm going on vacation.” I'm like, "Fine, whatever."

It's a lot of flexibility with that. Would you agree that success in our industry could be defined as a completed plan of care?

There's more to it than that. It's a completed plan of care, but it also depends on what your ultimate vision for the therapy you’re delivering.

Tell me more.

A few years ago, I heard Shirley Sahrmann said something along the lines of she would like to see PT the way we do dentistry in the sense that you're involved throughout the lifespan. I liked that idea. I've said it to patients before who I'm like, "You trust me when you're injured, but you don't even think about me when you're healthy." If you're going to trust me when you're injured, I should be the one, not your personal trainer, who's taking you through your wellness and fitness goals afterward.

PTO 38 | New Clinic
New Clinic: There is a matter of science of a plan of care.


Since spending time on our wellness plan, we've gotten a good number of conversions with that. It's the same argument though I see where they'll currently have a personal trainer still after getting hurt, paying the personal trainer X number of ridiculous dollars per hour session and they complain about their $20 copay. I'm like, "What is going on here? It doesn't even make sense.” When you asked me what my goal is or how I'm calling it success, I think having them for their lifespan in the context that they want. Like during rehab, I'll say it's a context we want to some degree because there is a matter of the science of a plan of care. In terms of wellness, it's up to them to some degree how they're defining their own wellness. I tried to do a good job of being honest with people and letting them be independent in their own decision-making. I don't like pushy salespeople so I try definitely not to be one. I try to not bias their opinions because I've seen it. We've all seen a placebo effect in sales or in treatment. Sometimes I'm being too much of a nice guy in that regard. I could drill down for what I need either financially or personally. There is a degree that we all share as PTs like a co-fulfillment where if they're satisfied, you get some satisfaction out of knowing that you provided that satisfaction.

It sounds like you listen to the podcast, but this is how you're built. This is a relationship-centered process. In other words, you're investing in that person. There's reciprocity. They care back enough so that you are combining efforts to get them where they need to go. Back to what Shirley Sahrmann says, we've built a profession based on an episodic process. It's an episode of care, but yet you're already saying, “I don't want this episode to end. I want this episode to end in the context of a pain or a disease process. I want this to stop, but yet I don't want to lose the relationship with you.”

I definitely want to make it clear that I don't support the concept of therapy forever.

It's not therapy forever but it is a resource available to them forever. That's a totally different thing. I still enjoy when patients email me or call me and said, "My shoulder hurts again. Do you have any thoughts on this?" I said, “Come back in. Let me take a look at. It's easy, really quick." They'll say, "Okay." We have 80 new customers into this organization every month. Start doing the math on 80 times 12. We have a bunch of clinics. Nathan knows what this feels like, but you can count the number of new customers you have every month and the degree to which you've established in one metric to measure this. The NPS is useful because it does truly give you some sense of loyalty to the brand and to who you are. Your ability to execute an NPS at some point in the plan of care is going to be important. I'm an advocate of getting clear on the front end, the very first visit.

I'm a big fan of asking specifically, "How was this for you?" That question is going to be responded to with the information. The information is going to come to you with some words, and you're going to get somebody language that’s going to communicate something, too. If and when you nailed it, and this is for any therapist and any practice, if you establish that therapeutic alliance upfront and they have truly this ability to connect with you, and there's some interesting research on that called attachment style, when that happens, the likelihood that they're coming back is very high.

Secondly, the likelihood that they're going to stick with a plan of care is very high. Lastly, the likelihood that they're going to call you first and/or recommend you to somebody else is very high. If we had to translate back to the very first part of our conversation about the emotional side, the soft science, not the data analytical side which I believe is important to support the emotional processes and the biopsychosocial processes, relationship-centered processes, that kind of stuff should be reflecting the success of your level of engagement, your ability to engage.

Let me credit you, Matt, because you're considering this where it is now. I think this is why you opened up your own practice. A lot of guys just want to get numbers in the door. We've all seen the mill grinding process. They get patients in and out and that kind of thing. If I'm not mistaken, you want to be a practice in which you developed a relationship such that your patients come back to you throughout the lifespan, based on what you said.

That's where I think the gold is for a lot of practitioners who want to fulfill their purpose as something more than revenue creators. The guys who want to fulfill a personal belief that they can do better in this life and affect their community and the patients' best is the people who engage in their patients and create that relationship. That's a credit to you. It's also a successfully run physical therapy practice that achieves your purpose, and that is to create those raving super fans. I talked about it in Neil Trickett’s podcast. It is where social media can help. It is where you can engage with those people who have already engaged with you and keep them abreast of what's going on in your clinics. It keeps your name in front of mind. Physical therapy, unfortunately, over the years has become a commodity. We've commoditized ourselves. When people say, “Physical therapy didn't help me,” then we did our patients wrong.

People reach out to social media to connect. Click To Tweet

Instead of saying, “Matt Esrick is my physical therapist.” I'll ask Matt what I should do about my musculoskeletal injuries. When you have that person, when you've won that person over, that's when you become successful. The fact that you're thinking about that now at the young stage in your practice puts you leaps ahead of other physical therapy owners because they might not be focusing on that. Retaining those patients and creating patients for life is where social media can help. Some email campaign newsletters can help to keep your name in front of mind. You don't want that person to go back and have a knee surgery two years later and not remember who the therapist was that did well for him two years ago for his back. You want them to tell the doctor, "Doctor, I don't even know where you want to send me, but I want to go Esrick Physical Therapy.”

That's nurturing a relationship. Nathan, you hit it right on the head. I'd say the same thing. You're already getting the important juice about this whole thing.

Matt, what are you doing nowadays to separate yourself from those other three clinics around you? How are you niching out? How are you branding?

I should probably start with the name of the practice, Honest Physical Therapy.

Nathan, how does that feel when you hear Honest Physical Therapy?

This area of New York has been described by multiple consultants as the least ethical place to do business. We've had some fun with our logo, too, in the sense that one of the doctors in our building from a distance said our logo which looks nothing like Abraham Lincoln. It looks like a silhouette of Abraham Lincoln. It’s like a little parody logo. We do some fun stuff on shirts and stress balls and things like that. To differentiate us, the first part is getting everyone to understand that it's one-on-one. There is no one-on-one on Long Island that's not home care. I can say that for a fact.

If somebody wants to come out and correct me, by all means to prove it. When I graduated from PT school, I went up to 47 interviews. I’ve got 40 job offers. I worked in close to twelve to thirteen different practices all over the place, an hour and a half away to fifteen minutes away. I'm very confident in saying no one does one-on-one, at least in an outpatient setting. No one does it like this because it's truly private. I don't have any aides. I don't have any assistants. I have a front desk person. She's great. That's it. If you're the first appointment in the morning, it’s going to be me waiting at the door for you.

That's a deep relationship. Is that built for longevity for you? In other words, is that your model going forward?

It is. That's part of our branding. We have rack cards and stuff. The three things that are on our rack cards are always progressive, always one-on-one and always evidence-based. Those are the three things I've pushed. Those are basically the three facets of the business. I've promoted multiple different slogans. Merit is what drives our business, not gimmicks or greed. The list goes on. I've put my whole marketing hat on and put a bunch of slogans and stuff. When you talk about differentiation, the first is one-on-one because nobody offers it. That's the core of our business.

The second is the simplicity of how we do things. If you don't have that equipment at home, we're not using. If you want to go out and buy some bands, I will teach you band exercises. Otherwise, I'm going to get creative. We've had cops who do the Emergency Services Unit tests, which is an insane test. They have to crawl through a 24-inch, 40-foot long tube, grab a 200-pound dummy and low crawl it out. I literally built the tube for this guy. I will get into it. If you want to be dedicated and do it, I will go far and much more than the extra mile for you.

Did you take some videos of that?

We did. We didn't get to release, though, unfortunately.

PTO 38 | New Clinic
New Clinic: When people say, "Physical therapy didn't help me," then we did our patients wrong.


That's gold on social media, you know that.

It could be. It's also, "Do I want to exploit my patients like that for my own gain?"

Can I answer that question because it might deserve a reframing? It's not exploiting the patient. It's exploiting the concept that physical therapists can be this kind of a servant, this kind of an expert at creating an environment to help you get better. I hear what you're saying, but I'm sensing it is possible you have some limiting beliefs about the degree to which you can reach people with the integrity that you're approaching this whole thing.

I definitely will not deny that I come in with a bias.

I hear that. To what degree is that bias helping you or hurting you?

I think sometimes it is. Other times, that's why I'm talking to guys like you. I need that second opinion to be like, "Wait a minute."

I'll get to help you click the switch on that one. In large part, beliefs oftentimes drive our behaviors in business and with patients. Part of our skills as clinicians for sure and sometimes as business coaches, consultants, whatever role we serve, is trying to ascertain the beliefs that hold and drive people's behaviors. When we start to understand what somebody believes about something, we have a better shot at trying to ask the right questions that help them to reflect more in a helpful way to determine the degree to which that belief is helping them or hurting them towards what they want to achieve.

I love Honest PT as a name. You can do so much with that and you can get creative to the point, I can imagine walking into your front office space and your fee schedule is there for everybody to see. You're not going to hide it.

Our fee schedule is on Google.

It's up front. I'm not surprised that's how you work.

I'll tell you, and this is where scalability and other business process, I get questions from patients who are like, "How does the bill work and stuff?” I'm like, "The standard visit is a half hour. I'm going to bill you two units. That's all there is to it. If your insurance pays more than our cash rate, fantastic. If it doesn't, we'll figure out what we need to do.” I also don't use modalities. That's one of our differentiating factors. I rarely used TENS, if ever. I don't have hot packs. I don't have ice packs. That's not skilled therapy, you can do that at home, at least that's my opinion on it. I do have some reservations about doing laser. The research on that is getting a lot stronger, so I'm coming around for that a little bit. Still, as part of while you're doing an exercise and for at least peripheral neuropathy, I'm a big fan of the neuromuscular stem.

People make emotional decisions based on relationships that they trust. Click To Tweet

Going back to what John was talking about in that you can definitely look at posting a video of your care in a couple of different lights. You said it's exploiting your patients, but I don't see it that way. I see that here's an opportunity to set yourself apart and be honest in how you treat. This is the social proof of how I treat and how we hold true to our values into our mission statement as a company. It is possible. It's a great idea to post some video like that like John said, simply because that sets you apart.

You can look up right now on Google and find a thousand different ways for physical therapists who posted their video about how to correct a shoulder or help shoulder pain. You post something like that where you're helping a New York policeman pass his test, there are not a lot of videos going around. That might help you stand out. Does that give you a bit more patients? I don't know, but it sets you apart more than anything. It can be cool social proof. John went down and did a dive into our limiting beliefs. Some of those things that might be holding you back, especially at this stage in your practice, you might want to be a little bit more open to doing things a little bit differently that are in line with your purpose in the name of your practice.

I have some definitive ideas for video. I should go back and change my wording a little bit when I said exploiting patients for my own gain. It's too strong of a word, but we're talking about relationships. I feel like you're taking that relationship and you're turning that person into an asset in the commodity sense rather than as a person.

Rather than exploit or commoditize the person who you're helping, I would flip that and say what you're doing is you're capturing the story of the situation to make sense. It's not the person. In fact, I would probably take great measures to keep the individual out of the story. There are a bunch of different risks right now that in HIPAA and a bunch of other things if you could stay away from, it would be ideal. Instead what you do is you use it as a case example and say, "I had a great opportunity to help a New York cop prepare for a very vigorous test. What was interesting about this is he had to do this. Can you imagine having to do that? Here's what we did. We created a thing. We did the thing. We pulled the thing around and next thing you know, this guy was killing it. It was a lot of fun. That's what we do here at Honesty.”

You've not leveraged the person. You've captured the story. It's the story that you're able to tell about your creativity in the context of helping people. People are like, "This guy gets creative and spends some time and thinks through it." That's a value proposition for many people. Oftentimes the experience elsewhere is that they're going through a cookie cutter process. It is unfortunate. It doesn't help our profession at all. It creates a tremendous opportunity for niche guys like you who are planning. You're in this to engage and spend the time, and that's it. You're going to get paid a certain amount, and that's what that's going to look like. However, you can be the best at doing that because you're telling compelling stories about how it is that you approach it, not necessarily what you do, but how you think about it. You could do that with every single case story that you come across.

It comes back to promoting yourself because, in comparison to the three other clinics around you, they've probably got pretty loud voices when it comes to marketing because they've been around a long time, whether that's because of word of mouth or their marketing engines and whatnot. If you limit yourself and keep a small voice, then you're not going to stand out like you want to. In order to promote, you've got to come with a loud voice that's specific to the people that you want to attract.

Matt, if that runs up until a belief barrier about self-promotion, one way to start to reframe that is what you're doing is promoting a mission. You're promoting something that you are promoting. You're speaking to the higher purpose of what you're doing. You're not out there saying, "It's me doing all these awesome things." It's, “What we've created here that affords our ability to serve people in this way.” Do you see the subtlety of the difference?

I like the reframing there.

That's exactly what it is, and sometimes by standing on that platform versus, "I’ve got to stand up and I've got to sound smart because this is about me." That doesn't work for me either. I know I might even get more traction by talking that way. The truth is I'm here to serve a purpose. I'm trying to help people in a way that's unique and interesting, "If I can help you with that, I'm happy to do it." That's a good reframe and it might be useful to stand on that and see what comes up.

PTO 38 | New Clinic
New Clinic: It's a great idea to post some video simply because that sets you apart.


I'm definitely going to try that.

You had a question or you wanted to bounce an idea because you had an opinion from somebody else, which is awesome and you wanted to get a sense of how two other old guys would reply to the idea. That's cool. Lay it on us.

I spoke with another business coach trying to get his feedback on the practice. We didn't get into numbers so much as much as I told him the situation I told you about how it started, where we're at now, and growth. The part that I also told him was essentially exit strategy that I started with. I have a partner in my practice. He's a minority owner. He has 30%. I have 70%. More or less a silent partner. He has his own practices on the east end. He's successful with that. He's a good friend of mine. He understands that I know the business very well. He was like, "Roll with it. Do what you want to do." I'm very happy that he supported me in that.

He knows that my wife and I want to move South preferably like a year or so after we have a kid, which we don't have yet. Hopefully, we'll have one soon. Everyone is like concluding. My father who was an entrepreneur was like, "Why are you starting a practice if you plan on leaving it?" I was like, "I like the concept of annuities where I can maintain ownership in something even if it's little and be far away. I grew it in the context I want to grow it in. I get it running the way I want to run it. Now somebody else can take that model, run the fit, and it's making me money past it. I liked that.”

The exit strategy was essentially to train someone else probably about a year out from when I plan on leaving to more or less fill my clinical role, even offer them a profit share to keep them interested in and be involved. At least in a one-on-one environment, if they don't have a profit share, they're probably not going to do the job to the best of their ability because their vested interest is significantly less. We were going to do that. Possibly flip flop our shares or rework our share so I'm no longer a majority. I'm a minority owner.

That was essentially the exit strategy once we reached the metrics we're looking to reach. Who knows, maybe someone will buy us up? You got the pro PTs of the tri-state area expanding to 100 practices in under a year or something. You never know what's going to come knocking on your door. Not that I would want to sell to them, but who knows when the situation happens, what's going to happen. The exit strategy was essentially that. When I spoke to this other business coach, I told him that. He's familiar with the New York environment and what it takes to be successful or highly competitive here.

He suggested I change my business model to more of a hybridized model, like a tiered system, which would involve a little bit of expansion, which I personally don't think we have enough volume to justify, and then bring in other staff. I was like, "I get why you'd want me to do that, but if I'm not at the growth stage that I want to be in, I don't know why I would choose to do it." Ultimately, after more discussion, I was like point blank, “What do you think my best move is here either in terms of marketing or overall to grow it?”

He flat out said, "You should close because you want to go down South anyway. Go work somewhere for a year, year and a half, however long it is, make as much money as you can to support that ideal environment because you started off and you've even said it. You started off in like the least ideal business relationship set up.” I get that there's that bias you go in with one of my favorite quotes from Will Rogers, "If you find yourself in a hole, stop digging." You could say I was in the hole when I started and I kept rolling with the punches. Now I'm out of said hole. I need to keep growing rather than go back in the hole. I was curious about what your opinions are on that. He only had a few facts about the business, but he flat out was like, “You should ax it.”

A successful practice is accomplishing the purpose of the owner. Click To Tweet

What's the temperature in New York?

It's four degrees. If you see me shaking throughout this, that's because our heat is not working.

I'm in Arizona. It was about 72. South, I don't know. Nathan is in Alaska. I know what he's doing up there. There are a lot of reasons to move South. You keep using the word growth because that's a big situation to dissect out. You're talking about growth and if I heard you, you're saying that if I have a certain amount of growth and I get to a certain growth point, then that's going to trip a number of other things. The whole rest of that exit strategy is fraught. It's fraught with a lot of assumptions that have to happen as a good Julian. They're not bad assumptions, but there are a number of important things that any success, I'll use generative business or successive business process, must have a totally different conversation. None of it can happen until you get a certain amount of growth. Growth is a process of determining you're here and you want to get here.

My sense is that you already know the difference, the gap between the two. You're running an evidence-supported, numbers-driven, data-supported business, you go, "I'm going to need this number of new patients, and this number of new patients statistically typically is going to net me this number of visits per new patient. Over a period of time, each new patient is going to get a referral of an additional new patient as a result of their efforts, etc.” This is an area regressive analysis type cool stuff if you're into that. If you're a spreadsheet guy, you should be doing this until Tuesday. The very first step is hunkered down. It's nice to ask these exit questions. Nathan would suggest every business owner do that. I totally agree with that. It seems as though the very next step is to figure out what would be necessary to get that growth. What's the gap? You've got a specific business model. That business model, I would say, does not lend itself to aggressive growth.

The reason that all of the chop shops are doing this volume business is because doing a volume business nets you a bigger margin. A bigger margin makes you a little bit more attractive to an investor or someone who wants to get into it because they're interested in the revenue and the margin that it’s going to produce. The real question is how do you take a niche business, a niche customer-centered and relationship-centered business like you're talking about, and find the right successor, someone who'd be willing to follow you, buy you out to some degree but leave you in it because you're still adding value, and have processes in place that they can follow to maintain the equity of your brand? What you're going to be leaning on at some point is brand equity. At this moment, the equity is you. People are leaning on you. The relationship is with you, not with the brand. If you move to Tucson or some other awesome warm place in the world, you're going to leave that place. Back to what Nathan was saying, you're going to want to go see Matt, but Matt is not there anymore.

Some of that though is the training and introduction because I've worked in practices that are larger where they have that issue.

Part of your investment is in the successor about how to transition those relationships. I'd have to say that you'd want a very robust process of measuring the degree to which you have a relationship with your patients, with your current customer base. To what degree do you have a relationship with your patients? If you have that, use that in a systematic way in order to improve the process of engaging these people, even with your successor.

That crossed my mind before. My partner does a lot of clinical instructing. That's in fact how we met. We thought about grooming a student probably in their third year at his clinic, and then transitioning them over to partner with me. They have that introduction. They get it on the system and we do it that way. The question is, will we have the business at a point where we can sustainably bring on a person who is essentially co-treating?

That's where you’re now, I would say, in the stage of execution of an idea of a plan gets a throw down on that because you can't even consider the next thing until you succeed in this first step.

You have to be successful in transitioning from a Matt Esrick centered clinic to an Honest PT reputation in your community. I'll follow up with John because I had one question come to mind as you were sharing your story, and maybe there's more to it. Why aren't you heading South right now and doing what you're doing? You and I both know that reimbursements are greater down South. You can pick off any place. New York has got the worst reimbursement. Why aren't you spending your time and energy down South creating what you're doing right now?

It's out of my hands in the sense that my wife is a New York City teacher. When she graduated, she had a scholarship where she had to work in New York State for five years or face the penalty fee that they ridiculously won't even prorate. We technically have the end of this year we could leave, but our families are both in New York. I don't want a newborn without its grandparents around for my own sanity.

That was my first question. My thoughts lean toward what John was saying. In order for the way you're set up, a lot of dominoes have to fall in the right direction at the right time to fulfill that. If you're going to do it, you've got to be intentional now with how you're building your practice, knowing your exit strategy ahead of time. You've got to make sure everything falls the right way. Kudos to you, first of all, for having an exit strategy. That's great.

PTO 38 | New Clinic
New Clinic: If you find yourself in a hole, stop digging.


Most guys don't and you need to no matter where you're at because all of us are going to exit at some time or other. The way you're doing it, the way you're set up, and the way you want to practice, a lot of dominoes got to fall in the right way. You've got to find the right guy that aligns with you, that agrees with how you're treating, that's willing to take on a partnership, and honestly to take on a little bit less revenue as a partner than you would partner up with another physical therapist with a different setup. Unless you're able to niche out, go out of network on a lot of stuff, go past cash-based, unless you change some things around, it's going to be hard to find that person. Still, to accept what your plan for succession is, a lot's going to happen.

I appreciate that sentiment. It is definitely a loaded situation. It's a lot better than exit strategy B, which is if we're not hitting the metrics. I have some regressions in place for what these metrics need to look like. We both decided like if at a year, we're consistently not hitting our metrics or we feel that getting the growth to the point where we're comfortable because sweating it out for like a year isn’t there, then give it the ax. Consider it proof of concept. It could work but in a different environment.

You can extrapolate some of your numbers to the average reimbursement of a different state and see if it works. You've done so well with your Excel stats. I'm sure you could punch in a higher reimbursement rate and see where your numbers are at that point. Do you know where you're looking to head down South mid-state?

It's still up in the air, possibly Texas, possibly Georgia. If she stops being a teacher, maybe Florida. Who knows?

There's no money in Florida.

I'm going to be the sole income of the household, but that's not going to happen.

You can be as an owner and you can do it. I know you can. With your focus, if you want to keep your wife at home taking care of your child, there's a way you can do it. Don't discount that. That can happen. There's a lot of value. What you're going through right now is a lot of learning processes. You're getting the numbers in place. You're getting your processes in place. You've formed your mission, vision, values, and purpose. You got an exit strategy. You know what you want to do in the next three to five years. There's a lot of power in that.

The important part is making sure that you are intentionally every week working towards the short-term goal that's going to get you here in the next six months, in the next year. If your head is down seeing patients 40 hours a week, then you're in trouble. You’ve got to make sure you're setting aside time for appropriate marketing to grow your business and all that stuff. You also need to have an eye down the road as the visionary for your company towards starting to develop relationships with colleges so that those students can start coming through your practice maybe on internships and stuff like that. Looking down the road, you've got to start doing some of these things to cultivate what you want at the end that forms an exit strategy.

We were planning different kinds of outreach. At one point, honestly, before I started the practice, I debated doing it as a nonprofit, which has its own gigantic can of worms unfortunately. It's good to hear all the different ideas that are out there to reinforce some things I had and some things that I didn't even think of. I appreciate that.

You could still do it nonprofit.

The gold is for a lot of practitioners who want to fulfill their purpose as something more than revenue creators. Click To Tweet

There's no benefit in the sense that loan forgiveness doesn't exist anymore.

I get it. It's very difficult. I'm still a subscriber. If there’s no margin, no mission. It's difficult to sustain the energy necessary. I'll keep coming back to what you expressed is that you're in it at a different level, you're just not swinging numbers. You're trying to be at some level, some pure essence of what a physical therapist can be. That's challenging in this environment. There are some ways to do it. It is going to require some absolutely hitting out of the park with relationship because those are the raving fans that you're going to need to sustain your business. You're going to have to be able to translate that and transition that to someone else. It's pretty powerful what you're trying to do.

You know your plan so well, Matt, of what you want to see and accomplish. From my previous episodes about getting a coach to essentially hold you accountable, if you let things slip, that dream and that exit strategy are going to slip further and further away, unless you're dedicated. I know I'm not.

It’s well-intended because you get the basics of it.

If you have a coach on board, you need someone to hold your feet to the fire if you're not good at that. A lot of us aren't. I don't know you that well, Matt, but that's where along the lines of my slogan, you got to reach out and find someone to hold you accountable and keep you on the path.

I've come to appreciate that more. I've told you before I was very much against the concept of coaches for a while. Maybe it's like the MBA and the business experience stuff because I'm like, "You're not going to tell me anything new for the most part." There are definitely things, which is why I have a partner partially for that. I will talk his ear off with ideas, see what he comes back with what's good and what's bad. He's been in the game for a while. I have come around with the coaches now. I got to thank you for that because I do like framing the mindset and changing the story. When you say things like they hold accountable, that totally changes it for me. I need that in a way. I'm my own worst enemy and best person for that at the same time, but it helps.

Take advantage of the network, the people that I've introduced you to on the episodes. You mentioned you liked what Michele Kehrer had to say on a previous episode. She sounds like she might be similar in practice to you simply on the vestibular side. There are opportunities to network with some of these people. They won't necessarily charge you, but if you want to pick their brain, I'm sure they'd be willing to talk to you on the phone for a few minutes or respond to an email if you have a question. Find ways to network. That's a great recommendation.

I know PPS has been doing their Peer2Peer NetWork. That's been relatively successful in the last few years. I saw an email that they're going to have some accountability groups or mastermind groups that are focused on cash-based businesses that might be a lot more along the lines of what you're doing, even though you're not all out of network. There are ways that you can get more ideas and maybe you'd get past some limiting beliefs. If a coach can hold you accountable, that's great. Those masterminds are pretty good at holding you accountable if they're working the mastermind correctly. They'll hold you accountable as a group. There are lots of opportunities out there to help you out to achieve your exit strategy. I don't want you to work it alone.

As you keep looking for a resource to help guide you through a process as we all need, there's a difference between a coach and a consultant. A consultant brings a lot of expertise, systems and knowledge. A good coach is going to help you grow and help you examine some beliefs that, once you reflect on them, you're going to say, "If I were to think about this differently, it would come to me and I'd be able to execute on it." Keep that in mind as you continue to seek this relationship. Both Nathan and I were there twenty years ago when we were trying to build our practices. There was always somebody in the mix who helped us through it, someone further down the road who can look back and say, "I've been there before. This is how it works." It saved my life more than once.

I have a question for you. I don't want to get into too much of the semantics, but I wanted to be clear about it. You keep using the word belief. I'm wondering why you're choosing that word belief because I wouldn't say my objections are using the belief barrier because the stuff I'm objecting to I have reason or support for. I'm not necessarily holding onto it tightly like you would have believed. I want to make sure I'm getting caught up in semantics or if there's a specific reason you use belief there.

PTO 38 | New Clinic
New Clinic: A lot of dominoes got to fall in the right way. You've got to find the right guy that aligns with you and that agrees with how you're treating.


I do use the word belief a lot in part because beliefs drive behaviors. Sometimes even as physical therapists, we’re trying to help somebody change a behavior such as a health behavior. We can try to change somebody's behavior by maybe teaching them something, making them more capable. However, it's not until you examined the reason or the belief or the value that they have for that behavior that it makes a difference. Oftentimes with patients, specifically when I teach this in courses, rather than try to change somebody's behavior by talking about behaviors, you do a better job of climbing a little bit higher in the meaning structure of how they organize in life, which is the belief.

What one believes is fairly predictable to what one will do. Oftentimes we may fail to execute on something because we're ambivalent about what we believe about it. We simply believe that social isn't that useful, so I'm not going to do it. It is, but if you can get somebody to help you restructure that and change its meaning, you might go, "I do believe in that. I didn't know I did." I think that's what good coaches are capable of doing. It’s reaching in a little bit deeper into how you structure the world and help you determine. Good coaches simply help you reflect on what's working and what's not. Accountability is useful, the personal trainer level of accountability, I would say. The physical therapist level of accountability could be one where it's a little bit more engaging, a little bit more transforming more so than, "Do this." That's how I'm trying to frame it.

I would say the same thing with the coaches that I've had in the past. The way where I thought they helped me out was questioning what I thought was true, giving me a different perspective on what I thought was real or reality and saying, "Maybe that is true. Is it possible that there's another perspective?" That's where a lot of value comes into play. That unlocked a lot of creativity for me to bring in some different thoughts and ideas that I didn't consider in the past. Not to say that my thoughts and ideas were wrong, but maybe there's a different reality to it, maybe there's a different perspective. When I did that, then that would change some of my actions, to go back to what John said.

This is great. If we helped, I hope that's awesome. For the audience, hopefully, if you have some of the same questions that Matt did, maybe we helped you guys out as well. John, I appreciate you sitting in on this. Matt, I appreciate you reaching out and sharing your thoughts and ideas about the podcast. Maybe we can do this again sometime, that would be great. Thanks for sharing and being willing and open, Matt, regarding your business and to John, for sharing your insight and taking the time out of your schedule to do this as well.

Matt, it's great meeting you. Seriously, you get some great things going on.

You too. Thank you both. I appreciate the time. I'll probably reach out to you, John.

John, do you want to do a little promotion here in what you're doing?

The relationship is with you, not with the brand. Click To Tweet

It's promotion but more, Nathan, back to what we've talked about even before we consider even doing this. It's fun for me and I think you said the same thing, to be able to talk to business owners who are on the path that we were fifteen, twenty years ago. It's absolutely fun to look back and say, "Back to the story, I had someone like that at some level give me some advice.” That's helpful to go, "Yeah." When we have an episode like this, this is as much of a case study in a relational process with Matt or whoever it is, it's always a good process.

I congratulate you in having a podcast and source in this way. I'm the guy with patient success systems. That means that I'm helping to coach and consult to help build relationship-centered care. What I've learned in this process, it's not about relationships with patients but it's a relationship with yourself, your relationship with your mission, and the degree to which you're able to serve in the way that you're called to serve. I'm saying it's a lot of fun to engage in this way.

How can people reach you, John?


Matt, good luck with Honest PT. I wish you the best. I'm sure we'll stay in touch.


That was cool, John. I appreciate you bringing that up and inviting me to bring Matt on the podcast and discuss some of the questions that he had. How do you think it went?

I thought it went great. When you listen to the challenges that he's dealing with and the depth of questions and what's important about the next steps for him, we're all dealing with that at some level. For him to come out and talk about it and for us to give our slant on it from again, guys who are gray beards on this, I think he's on his way to figuring some things out.

I was impressed that Matt does have his stuff together in a couple of regards. He has an MBA so he has a leg up a little bit to begin with, but he's tracking his stats and he has an exit strategy. Those are two things that not a lot of us beginners start with. He still comes back to some similar issues that we all deal with in that we can learn as much as we want to about how to treat somebody. When it comes to interacting with doctors' offices and the desk person and how to work towards that exit strategy, those are things that you don't necessarily learn in any schooling even if you do have an MBA. It's valuable to have people like you on and other consultants as well to discuss some of those interactions that we still have to have on a regular basis.

It was a great opportunity. Thanks for having me on to do this. We should do it again.

If anyone out there is interested in reaching out to John directly to get some coaching/consulting, whatever it might be, he's available at If you also want to be on the podcast or you have some ideas for me, as Matt did, feel free to reach out to me at

Important Links:

About Matt Esrick

PTO 38 | New ClinicMatt is essentially the driving force behind Honest Physical Therapy. He runs the show, treats patients, and is an avid devourer of the latest research. When he isn’t helping you in the clinic or vetting the latest evidence, he is usually hiking with his Aussie Cattle dog mixes (Ellie & Miles). Matt can also be often found on his surfboard, paddleboard, snowboard, or bouldering. A former competitive athlete, Matt played Division 1A Hockey and Rugby, and had an amateur boxing career, only to later hang up his gloves to become his wife’s latin dance partner. Because Matt has been lucky enough to travel most of the globe, he’s got some interesting tales of adventure.


About John Woolf

PTO 38 | New ClinicJohn Woolf is a physical therapist and athletic trainer. He studied physical therapy at Northern Arizona University and soon after completed a Masters degree in biomechanics and motor control at the University of Arizona. He was the Head Athletic Trainer and Director of Sports Medicine for the University of Arizona in the ’90s and then entered private practice at ProActive Physical Therapy in Tucson, AZ where he was the CEO of a 9-clinic organization.

In collaboration with a faculty based at Texas Tech University, he runs the International Academy of Orthopedic Medicine – US, a continuing education company that teaches physical therapists, and medical providers in the US, Europe and in South America.

With this group, he developed a course that explores the neuroscience and the general impact of the patient-provider relationship in the clinical outcome. He teaches this course to providers and health systems in the US.

He explores these topics with clients through coaching and consulting company, Patient Success Systems, that provides health care providers and organizations with systems and specific training to improve outcomes through patient-provider relationship training, change the language and relationship-centered care. He is currently completing a Ph.D. in performance psychology.

He has lectured as clinical faculty at the University of Arizona’s Surgical and Non-surgical Sports Medicine Fellowship Programs in the Department of Orthopedic Surgery and Family Medicine. He lectures for the University of Arizona’s Integrative Medicine Program and is on the clinical faculty in the AT STill University Orthopedic Physical Therapy Residency program.

He is proudly married to Chris and has two children, Natalie 22 who lives in LA and Timber 20 who is a freshman and Northern Arizona University.


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PTO 18 | That One Thing


What if I told you that if you focused on one thing, it would return you over $100,000 per year, would you be interested? Heidi and I continue our conversation about the current state of the PT industry and business ownership, and delve specifically into this topic. PT owners are losing money, over $100k per year, because they and their PTs aren't getting patient buy-in to PT services. WebPT's report showed that 90% of patients aren't completing their Plan of Care. Improving that one thing, if focused on with every provider in your clinic, will immediately make an impact on you and your patients. Imagine the benefits - improved outcomes, improved reputation, improved referrals/word of mouth, improved financials, etc. What would you do with an extra $100k this year? Shoot me an email with your response and I'll send you a gift!


Listen to the podcast here:

WebPT’s Heidi Jannenga Part 2 – Earn $150k More by Doing This!

PTO 18 | That One ThingThis is part two of my interview with Heidi Jannenga of WebPT. In the previous episode, I shared her bio and story. We discussed some of the issues related to physical therapy ownership and our lack of marketing and growth strategies. This is all related to WebPT’s report called the State of Rehab Therapy in 2018 where they surveyed over 7,000 respondents in the rehab industry. We talked about marketing and growth strategies in the first episode. In this part, we go into three of the four topics that stood out in the report but the main one being is that we’re losing money. We’re losing hundreds of thousands of dollars in our PT clinic businesses simply because patients aren’t completing their plans of care. Heidi and I talked into that a little bit as well as a couple of the other topics that came from the WebPT report. If you want to learn more about Heidi and her story, go back to the previous episode. In this episode, we’re going to move forward into the conversation and talk about the rest of the results from their report.


I wanted to go into that part of your report as far as patients not completing their plan of care. Did you recognize through your surveys what factors were involved that might be limiting people to not completing their plan of cares? Do you have some ideas through your conversations and perspective that might play into that?

Let me give the data first and then we can talk about some of the whys after. We noted that about 70% of physical therapy patients fail to complete their course of care, which we also equated to be about $150,000 for an average PT practice. Based on 2018, it was even worse. We saw the patient dropout problem to be about one in every ten therapy patients who didn't complete their prescribed plan of care. Only 10% of everybody who walks in the door completes their plan of care. With copays and deductibles being as high as they are, if we're not having that communication from the get-go with the patient of understanding, “In order to get this kind of outcome, the expectation is you're going to come for ten visits,” for them to feel comfortable in saying, “I have a $50 deductible, $10 is not doable.” “Let’s work together to figure out how do we make sure that you still get the great outcome and maybe we can figure out how to space that out over more time that’s going to take eight or five visits. We'll figure it out if you are super diligent with your home exercise program.”

PTO 18 | That One Thing
That One Thing: Our core is the EMR, but on top of that, we've added many more digital tools for clinics to run their businesses.


Number two, we've always gone off of maybe the prescription from the physician or referral from the physician to create our plan of care. The physician arrives two times a week for three weeks while we stay two times a week for three weeks and call it good and say, “Six visits is what we need,” versus using expertise and our knowledge. We're able to help with predictions on this too. This is what's exciting about our analytics program and reporting components within WebPT. We now have learning on, “With these comorbidities, you can expect more of this outcome and it will take eight visits.” You can have a more accurate prediction, based on data predictability of how many visits it might take so you have a more educated conversation with the patient. It’s a shot in the dark and we just maybe see the prescription so maybe we knew all along that it wouldn't take ten visits. It would only take eight, but you said ten just to make sure it covers because you don't want to have to go back and get another referral.

The tough thing is number one, we don't learn how to have those conversations in physical therapy school. If you've got a great CI, then maybe they helped you along that path, but it's valuable upon the owners to make sure that they're doing sales training. We've got to initially show them the value that we can provide. Number two, it’s worth it financially for you and your health to fulfill this plan of care. We've got to be empathetic as to the financial burden that it causes. We also have to recognize that if we're not able to complete our plan of care, we cannot guarantee their health. That turns into the patient that walks away and says, “I tried physical therapy and it didn't work for me.”

If we are able to have that conversation in the first place, then there's a cascade of events that it goes into play. It ends up being not good not only for that patient because they're going to have issues down the road if they don't finish up their plan of care. Number two, it's going to look bad on our clinic and on our profession. There's a whole cascade of issues. The training for a physical therapist to have that conversation at the very beginning, at that very initial exam is invaluable. It can benefit us financially. It benefits the patient, our profession, clinic and our reputations.

There are many things that can help with that. I get excited about it sometimes because I remember listening to a podcast by a Paul Gough and one of his first episodes talked about it. Paul’s in London or England and there's a nationalized healthcare, but he doesn't participate in that install cash-based. He's busier than he ever needs to be because he’s really focused. He trains on that initial conversation and so it's imperative. I want to make the point that owners need to recognize what their therapists are saying in that first conversation to get buy-in. What are they doing to educate? What are they doing to work together with the patient? What does that conversation consist of so they complete their plan of cares?

If you don't have a website that truly reflects what you do in your practice, you’re missing out. Click To Tweet

When I was a director and I had therapists, it was hard to have some of those conversations unless you sat in with the patient visit and you understood what was happening because you didn't have any objective data to go on. Now, you do have more opportunities for objective data. For example, with our outcomes platform, you're able to see therapist’s utilization for specific diagnoses and what outcome they're getting. If you have people who are outliers and are getting the same outcomes, but it's taking them fifteen visits versus on average while every other therapist is taking ten or if you have dropout rates for a specific therapist where their cancellation and no-show rate is significantly higher than anyone else in your practice, there's very clear education that can be done with that particular therapist.

Having those guys close to you and in a dashboard form, you can run your business through software like, “That’s what a lot of other people do in every other industry, why aren’t we doing it in healthcare?” At the end of the day, what we're trying to accomplish with WebPT is to have that tangible objective data where you can have a very pointed conversation based on objective data-driven decision-making versus just subjective like, “I’ve got a patient complaint, is this true?” We had to do it that way in the past because we didn't have access to this data, but now you do. It's important as owners to take advantage of that.

I noticed in your report that the compliance to plan of care was worse in the bigger organizations. Those PT clinics that average between $1 million and $5 million in gross revenues had some of the best averages, but those who were in the bigger organizations had the worst compliance.

There are a lot of complaints sometimes about the cool “corporate healthcare” and how it's turn and burn situation and all they want is revenue. I don't believe that because I know that every clinic is different and it's about the people in the organizations. Just like any organization or company, you have a culture and if that's your culture, then you're not going to get the best outcomes. It is interesting that there were significantly greater dropout rates as the clinics got larger. It's also a function of numbers too. You have a lot more patients running through these larger businesses, so those numbers may drop a little bit more.

I’ll make a point so that owners, specifically those who focus on growth, recognize that that can slip away. There's a crack in the ship there that could be a loss of finance, revenue and reputation. It’s important to note the $1 million to $5 million gross revenue mark. As you get bigger and as you take on more clinics, you can start losing sight of that initial contact with each patient. That training is probably something you want to nail down and clean up with all of your therapists.

PTO 18 | That One Thing
That One Thing: We're still not getting to the people that truly do need us. They're seeking other avenues or physicians handing out medication.


It's imperative for those executives in those organizations to understand how important it is for those completions of care. When it comes to their outcomes, there's this cascade that happens. You have this unique opportunity to do some education on the forefront. That could create a lot of dividends as we showed with the amount of dollars based on the number of visits that you're losing.

One of the other things that you said that was important to you was the discrepancies with the gender pay gap. Talk to me a little bit about that and some of the factors that might play into that.

We had more than half of our respondents and we asked them about their salary ranges, most of them fell within the range of $50,000 to $90,000. The average PT right now is getting paid about $70,000. If you look at the census data, it all correlated well. Males were more heavily represented in the $70,000 and over salary segments whereas females were much more heavily represented in the lower than $70,000 range. The biggest piece that I wanted people to take away from this is the expectations from the get-go. We’re not unique and the whole salary gap conversation. We will definitely do more in our next survey because there are lots of people that work part-time. It's not just women that work part-time, but there are lots of people that work part-time.

To make sure that we have some of the nuances behind the lower paying wage information is going to be important in the future. Even for that first job, what the expectation was for male therapist versus a female therapist was significantly less for females than it was for males, going into their first job or even going to any job. Coming into it, there's already a gap, which was frustrating to me because, “Why does that exist? Why does a female therapist think that she's less valuable than a male therapist?” You can pile on top of the gap that in general, females tend to negotiate less when it comes to salary grade.

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All of those things come back to education right from the get-go in PT school and talking about how important it is in some of these negotiation tactics, but also realistic conversations. What we also hear is the reality of what an average PT will make coming out of school versus what they've been told sometimes academically does not necessarily match up. Knowing regionally what the average pay is because that regionally changes as well. It all comes down to knowing the business of PT. Knowing how reimbursement rates, payment rates, all of that has to affect how much you're able to get paid, “If I don't get reimbursed, if I don't get paid for my services, I can't pay you what you want to get paid. You’ve got to have money coming in to have money going out.” We’re also remising this in PT education on the business side of physical therapy of how the whole process works from the time you treat to the CPT code that you bill for, to the judication of your claim to coming back in. It’s knowing how much it costs to run a business and the liability insurance.

All of those nuances are important for people to understand. You ran a business for a long time, you understand P&Ls but you don’t even know how to read a P&L. It is basic business knowledge. That’s why we did our second event, which is Ascend Conference that WebPT puts on. It's an annual conference and it is specifically focused on business and how to run a business. We run two tracks, we run a small business and new owner track and then we also run an enterprise track of those that have been in business a long time running with much larger practices. There are two tracks running simultaneously and some amazing speakers who will come in. We're all together as a group, but we have had a tremendous response over the years. This particular year, it’s coming up on September 27th to 29th. It is WebPT’s 10th year anniversary. If you are in Phoenix, Arizona, feel free to go to or search WebPT Ascend and get your tickets because they’re going fast.

I'm impressed that you're doing it because I don't think there is enough of that out there in our industry that is separate from the APTA. I have nothing against the APTA, they're working hard. It's imperative that some of the more grassroots events take place so that we can get together and network. Also step out and see what's happening outside of our bubble.

PTO 18 | That One Thing
That One Thing: Last year, 70% of therapy patients fail to complete their course of care.


If anyone wants to buy a ticket, you’re going to have a PT code and it’s PT Owners Club. If you put that in, you’ll get a discount on your ticket.

I invite everyone to go there as well. Take the time. From my experience, taking a week or a day coming away from patient care and attending some of these events can be hard to do, but it's imperative. Honestly, if you're a business owner, you've got to wear your business owner hat first and know what's going on in the industry. You've got to know what best practices are and it's out there for you. You've got masters and experts in PT business that will share the secrets. They'll show the blueprints and you'll come in contact with other therapists who are going through the same issues. Some of them have overcome what you're going through or you've overcome what they're going through and you can share.

We love taking extra time to provide for networking. After every session, there's an elongated period of time where you can digest and talk about it amongst other people. We have found that one of the most valuable parts of our conference is to make sure there is ample time for that networking and sharing of ideas from what you learned and how you're going to implement that immediately when you get back to your practices. We also do have some folks from outside of the industry coming in and sharing. With us continuing to tell ourselves what we're doing right, not doing right, sometimes it’s important to get ideas outside of our own industry and the best practices that have worked elsewhere that we have found like, “This can be applied to PT.” It’s going to be a great time.

Having a therapist be the alternative to pain medications is an opportunity that we need to be seizing. Click To Tweet

Thanks for sharing that information. I'm sure there are not a lot of students that are reading this, you alluded to this at the mounting student debt issue. If there is a student out there in the audience, what's your advice to overcome that debt and schooling issue?

I would say press on, know the reality of what it is to be in the PT industry, and know why you got into it from the beginning. Most of it was to help people. We're on the cusp of blowing out much more of that 90%, especially if we're able to attack this with the grave issue and be a strong part of that as another provider that can help those folks. There's a lot of evolution that's going to happen hopefully over the next few years that opens the opportunity for more PT. This isn't just a conversation for students. This is a big conversation that needs to be had from owners because they're the ones that are hiring these new grads.

The cost of what they're coming into or the debt that they're coming into your business with is high. The burnout of having to not only work a 40-plus hour work week that you're going to ask them to do, but most of them will probably also be working on weekends and everything else. It's not anything different than I did when I came out of PT school. I also worked for DM on the weekends to help finance my pre-med out as well. It's a much larger amount of debt they're coming out with. They have over $70,000 in debt that they're coming out with graduation and more than a third are coming out with more than $100,000 in debt. That's not including any debt that they accumulated through undergrad.

That can be a big stressor. As owners, we need to be cognizant of that.

PTO 18 | That One Thing
That One Thing: What an average PT will make coming out of school versus what they've been told sometimes doesn’t necessarily match up.


Having a frank conversation with academia to understand the reality of our business and our industry to hopefully disrupting the education process of how we continue to attract the best people into our profession. What was disheartening to me was when we put out this blog about student debt, the conversation was around how therapists are discouraging people from coming into the profession because of how hard it is. You're limiting the best of the best that you want in our profession, and you're saying, “I'm not sure if you want to think about PT, it's been hard. This is what you’re only going to make.” Rather than the benefits and all the pride you have in who you are, it's the starting to become a more negative conversation.

Regardless of what tools you're using, it's imperative that patient experience is seamless but also shows value. Click To Tweet

We heard from students too who are saying, “I love being a therapist, but after a couple of years of knowing how long it's going to take me to get out of debt, I'm going to go to some other industry that I can use my expertise in. I can't keep doing this.” It was disheartening too because now we're losing some potentially best people out of our business into another practices and industry into another industry. That's not sustainable. If we’re going to continue to push our outcomes and value, we have to have the best in our industry that want to be here for the right reasons. We have to start some frank conversations about how we can disrupt our thinking about education. John Tiles with EIM, their group is doing a lot of amazing things with the two-year program versus the three-year program. There are a lot of opportunities. It always takes the pain and pushes back to make change happen. We're on the cusp of having more pointed conversations and making some changes here quickly.

We need more PTs with the number of people turning 65 every day here for the next 25, 30 years. 10,000 people a day are turning 65. The demand for physical therapy's not going away. It's only going to increase.

It's still one of the top ten jobs that people always say that people want. When your pay is not commensurate with your debt that you're coming out with, if you can make an annual salary of $70,000 and you come out with $100,000 debt that has a 5% interest rate on it, if you’re paying a minimum it’s going to take you 45 years to pay that back. It doesn't sound appealing to a lot of people.

What is your vision? What are some of the exciting stuff coming up that you see in the PT industry or WebPT itself?

Despite all of that negative stuff, my faith in the industry is unwavering. The future is bright where there are so many people that are needing our services and our expertise. It’s about how we reach them and how we get our profession more well-known in the mainstream as the go-to for any kind of musculoskeletal injury. Also to work collaboratively with others that are getting those patients to understand what our expertise is, how we work together in a referral sharing way to make sure that we have access to them, but also that we can share. It's not just only our expertise that's going to help them.

A lot of people are now much more available to take patients in without referrals from physicians. Click To Tweet

For the WebPT side, there are many exciting things but right now we're working a lot with making our whole platform much more integrated. Efficiency is the word on all of our developers and product managers. A mindset of no longer having the oxymoron of EMR documentation efficiency happening, we want that to truly be a thing. We have some innovative changes we're doing to our documentation portion, the heart of our platform to make that a lot more streamlined for therapist student to get through their documentation portion. We're also looking at integrating more of the billing process to get those claims out as clean as possible and get that payment back into the clinics as fast as possible. Just enabling and empowering our therapists to run their businesses better.

PTO 18 | That One Thing
That One Thing: The heart of our platform is enabling and empowering therapists to run their businesses better.


Thanks again for taking the time and sharing your information and perspective from the report. Your personal perspective is extremely valuable. If people want to know what's going on with Heidi Jannenga or WebPT or how to get on webinars that you're posting, how can people get in touch with you?

If you go to and click on our blog posts, you can get those sent to you on a regular basis. I am on social media, my Twitter handle is @HeidiJannenga, so feel free to reach out that way. I'm on LinkedIn as well. There are lots of different places you can get in touch with us.

Thanks for your time, Heidi. I appreciate it.

You're welcome. Congratulations on this awesome venture into the podcast and with all your businesses. Thank you.

Thank you very much.

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About Dr. Heidi Jannenga

PTO 17 | Marketing And Growth Strategies

Dr. Heidi Jannenga, PT, DPT, ATC, is the co-founder and president of WebPT, the country’s leading rehab therapy EMR platform for enhancing patient care and fueling business growth. Since the company’s launch in 2008, Heidi has guided WebPT through exponential growth. Today, it’s the fastest-growing physical therapy software in the country, employing nearly 500 people and serving more than 75,000 therapy professionals at more than 12,000 clinics. WebPT has also ranked five consecutive times on the prestigious Inc. 5000 list and twice on the Inc. 500. Heidi has been recognized as one of Health Data Management’s Most Powerful Women in Healthcare IT, an Entrepreneur of the Year finalist by Ernst & Young, a Most Admired Leader and Tech Titan by the Phoenix Business Journal, among other accolades.
Prior to co-founding WebPT, Heidi practiced as a physical therapist for more than 15 years. Today, she regularly speaks as a subject-matter expert at local and regional technology, entrepreneurship, and leadership events, as well as at national PT industry conferences.

Heidi serves on the boards of numerous organizations, including the Arizona Science Center, Support My Club, the Physical Therapy Political Action Committee (PT-PAC), the Institute for Private Practice Physical Therapy, Conscious Capitalism AZ Chapter, and the Arizona Community Foundation. She also dedicates time to mentorship within WebPT (through her women’s empowerment group PropelHer) and in the broader community (through her work with physical therapy students and local entrepreneurs).

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