Seize the Opportunity: Alex Bendersky on Risk, Resilience & Trillion-Dollar PT

0:00 You're listening to the PT Pinecast, where smart people in healthcare come to make noise. Here's your host, Jimmy McKay. I'm pretty much just living live today here at Graham Sessions, the top APTA's headquarters, live streaming during Graham Sessions. And I'm telling people Graham Sessions is this annual event called the Cool Kids Lunch Table, super secret. But you know all these people. If you're rubbing elbows in the profession, you've met or heard of or at least you know know asymmetrically through linkedin a lot of these people alex benderski but i'm gonna show a bunch of times is this your how many gram sessions my number one is your first one it's my first one i'm grand session virgin really this is great we get purity uh so my big picture question would be uh what is something so far that's made you someone who thinks writes talks acts in this profession and we'll get to what you do but what's something that surprised you or excited you?

0:58 Let's go with positive first. I think the panel sessions, the panel structure is actually very good. It's a good format to get different voices. Go topic-wise. Anything that either is on the docket for later today or tomorrow or already that's made you go? okay cool uh the the strength of numbers talk is is definitely pertinent uh there's a laws of scale that can't long lever arm yeah the levers and the arms and the leverage talking about i mean and again the rule that the rule about gram sessions is you can't say who said what right let's talk about the idea and the idea there is uh can you find ways to connect with colleagues or other businesses without being bought formally, right?

1:41 And then how can you use those economies of scale to get things that are better, either better, higher payment or lower cost? I mean, think of the European Union, right? You retain your autonomy, you retain your borders, but you open them up so that you can have a collective bargaining, you can have collective currency, like just use that as a narrative for physical therapy practice. So you keep your autonomy and agency, but you are able to share some of the risk, able to share your borders. able to share some of their common expenses. So it's logical. Certainly there's movement in the right direction. It's not the only organization that's uniting. Hopefully there's going to be more of a grassroots movement around the country to do this, but It's still a fractured ecosystem.

2:23 And so by majority, we either lose private practices because they sell or we lose them because they close. What is something, my second question, what is something that isn't on the docket? You're the guy who reads the instructions, is my guess on you. What's something that you were reading and going, why are we not talking about this? I think the theme of diamonds under pressure. That's the theme this year, yeah. I don't know if it's closely related to the actual topics that are being discussed. I think it was just the theme, yeah. It's a nice theme. It sounds good. It certainly gets a buy-in. It's like, yeah, we're hurting. Let's see how we can get better. Teaching resilience is a skill.

3:03 I think to teach resilience, you have to have topics that actually empower you. to withstand some of that stress under pressure. And if you're going to turn this coal into a diamond, teach people how. Don't give them ten thousand years until they actually turn into that. We forgot to add that. It is pressure that turns coal into diamonds. It is also a long time. Yeah, for sure. It takes millennia. And if you want to expedite the process, you have to have an external source. You have to have that pressure source from somewhere else. So, yeah. If you were to talk next year, what would you say this needs to be on the docket, idea-wise? No, that's a terrific question. I think next year on the docket, you need to have a greater voice of other professions that are presented here.

3:48 You need digital health providers to be present. That's interesting. Half of the economic equity in physical therapy is digital health, and they're not present. PTAs need to be here. PTAs are the troops on the ground. They're the ones delivering care. I don't see them represented in any panels. So if you're going to have someone delivering care for you, they should have voice. Yeah, PTAs, and I'm not the policy politics part of PT. I like the fact that some other people do it, but PTAs were just getting basic rights in a PTA environment. mean still working for basic for sure right of course it was like why don't the ptas show up i'm like would you no exactly but how do you expect it economically to give them a bigger burden of delivery care process without giving them representation and giving them voice so i would love to see a broader representation we can maintain this exclusive pt only club yeah and still expect equity yeah uh what's something that not a lot of people have on their bingo card right now as we record in january that will become a thing in the next twelve months like something that people are not gonna see we'll say most people aren't gonna see coming in his issue there's a lot of policy changes law And maybe they're like, well, I saw the law change, but I haven't felt that yet.

5:05 What's something in the next twelve months that people are sleeping on that they're going to be affected by? So not to be a bearer of bad news, but your bread and butter of outpatient physical therapy business, your post-operative cases are going to start to disappear. Why is that? Your risk-based contracts, your hospitals become stakeholders in your risk. And when the hospital is a stakeholder in the risk, they will retain most of their delivery processes. So your mom and pop shop that is now taking care of your ACL high school population, which is great because it's like six months of guaranteed utilization. Once that disappears, what are you going to do to occupy your therapist time? So be aware of these models that are emerging. These are tenure models. And the reason why they're tenure models is they're not expected to be fully live until twenty, twenty seven, twenty, twenty eight.

5:50 But they're here. So your team, your access, your wiser models, they're here. They're a ten-year roadmap. They have a runway. And right now, you're just taking off. So are you ready to deliver care? Are you ready to collect outcomes? Do you have the infrastructure? Do you have the technology? So yeah, I think that's... All right, well, someone who's like, you said, I hate to be the bearer of bad news, but you were. What should someone be doing, reading? Where should they be skating to? I think one positive effect of CMS is there's full transparency about it. Right, they put it in writing. It's a lot of writing, but it's there. It's a lot of writing, but we live in a day and age where you have Chet GPT.

6:31 Right, right, right, right. Ask it to summarize it for you, and you become an educated consumer. I learned logical fallacies on the drive down here. I was like, I know they were a thing, but I'm like, teach this to me, then give me an example, then give me a multiple choice quiz. And I learned it in two hours. So it's democratization of information. It's wild. We are living in an age where knowledge is democratized. It's free, almost free. you just have to be a smart consumer so go to see a master website download those documents and ask chad gpt to summarize it for you step one step two look into your existing infrastructure are you ready to create a checklist create like go through the same chad gpt conversation and say what do i need to do exactly what i run an outpatient physical therapy practice in arkansas what are my steps to participate in these risk-based models?

7:20 Give me a checklist. Now you are an educated consumer. Now you're prepared. And then start checking off those boxes. The last part is really important too, checking off the boxes. Oh, for sure. We always want the brochure. Give me the checklist. I now feel safe. still need to act on it yeah i need you we need you to act on it you remember those days when dating was a thing right i remember that like i've been married for too long so my memory is very faint but uh you if you wanted uh somebody to respond to your phone call you have to make a phone call um so you you have to be the one taking the initiative and you have to be prepared so if you're gonna want to future proof yourself then start acknowledging that where your shortcomings are and protect yourself from them yeah uh what do you think of the room uh in terms of who's in it being this your first uh gram sessions and it's hard to see everybody right we're just seeing people walk around um but there's business There's academia.

8:16 There's small clinic owners. There's large clinic owners. There's product companies. Who else? You mentioned PTAs. You mentioned digital health. Who else needs to be in that room? I mean, peers need to be here. Why would they come? We're assuming that peers is one homogenous system. It's a heterogeneous system. There's parts of peer ecosystem, there's parts of their ecology that is interested in what we're doing. Really? They're just getting this information through a secondary resources and tertiary resources. Why not be here? Why not extend the invitation and see what will come? We don't extend the invitation. That's what Lincoln would do. We're looking at the Lincoln Monument over there, right over the hill. That's what Lincoln would do. Extend the invitation. There's no enemies here, right? We're looking at the same picture from different vantage points and expecting different results.

9:00 It's not going to happen. So, yeah, start the conversation. Start the conversation that's not haggling over prices, because that's already step three. You're haggling over prices, but you haven't established ground truths. Get them here to establish ground truths. Get somebody who has knowledge of payer sources. Right now, we're talking about payer sources from a consumer side only. So are you really getting an equal representation here? Yeah. The thing that frustrated me sometimes with people is we're very people-y. My first Grime Sessions was ten years ago. And then I went back a year. So I did it in twenty sixteen, twenty seventeen, or twenty seven, twenty eighteen, whatever it was. And the problem was we were talking about the same thing the second time. And I don't have patience.

9:42 You and I are right now in the hallway while the talk is going on. You and I are like, got it. I'm going to be outside. I need to walk around. I need to touch some grass. um why do we fail to do that sometimes well jimmy i i've been a physical therapist for i've been talking about the value we've been talking about identity this is not a new conversation it's funny because i come in and i go this is all so new and then yeah three six nine years later i'm like oh same thing yeah it's it it is the same thing there's it's almost ridiculous how reproducible this is and i fully expect in twenty twenty six twenty twenty seven uh nothing changes when nothing changes so and and we're in that same perpetual cycle of nothing changing yeah so and then we have agents of change so we have people calling for change but just calling for change without actually that's what it felt like it felt like what do we want change when do we want it now how will we get it someone else or i already did my part i said what should be changed but people are people are out there in clinics or satisfying right like you we want to maximize because ideally we want it all right but it's not a binary it's a spectral thing so you you have to satisfy so you have to accept suboptimal change but change is gonna come regardless whether you want it or not you can just drive the direction of change to a certain degree yeah do you remember that simpsons episode when uh homer or the mayor mayor was running for re-election and he came in the balcony and he said like all right people of springfield uh abortions for all and people were like boo and then he's

11:12 like all right people never mind them abortions for none and they're like boo abortions for some yeah everything's man Yeah, it is, it is. You just expect, if you want to be the agent of change, you have to be the active ingredient. You have to drive energy into it. I've got a social experiment going on that I thought would have some reaction, and it turned out having no reaction. I'll talk to you about it. What I needed to do was go further with this, and I will. So I dropped this in a Facebook group that, are you in Tony's Facebook group? I'll get you in there. It's meant to be a bunch of people looking to create content, alternative revenue streams for practitioners. What it's turned into, a bunch of people trying to solve problems different ways, which I like.

11:54 Tony Meritato, my normal co-host on our livestream, he tries to solve a thing a thousand different ways tony tries to fail as fast as possible which is good so i dropped this little social experiment i'm calling ninety nine problems pt edition and the idea was um We can't usually change the big thing first, right? Knock down a small domino, it'll loop to a second, third, then you get bigger. So my thing was, this came from an idea, I saw a guy talking in his community about medium problems. Medium problems are, first we need to describe large and small problems. Small problems are, you come out of your house and someone just left a bag of trash there.

12:36 I just throw it away. I don't call the cops. I'll solve it. It's stupid. It's rude, but I'll just solve it. Big problems are someone drives a dumb truck through City Hall. That's big. The town is going to take care of that. The medium-sized problems are like it's too big for one person, but not big enough to ever hit the number one list on the town. So he gave an example of how they solved medium problems. And he's like, I'm giving you an example that you should take to other places. So the medium example was there were parts of the city infrastructure like sidewalks in neighborhoods that were just overgrown. It's not really big enough.

13:17 It's not causing a fire. It's not causing a flood. So the town's not going to take care of it. But uncovering a sidewalk. is like a pain in the ass for one person. So he's like, we got a group of three people, and the three people all brought a friend, and now it's six. And then we did it, and while we were doing it, we shot a video, and then ten people were like, where's your next one? Next thing you know, you've got thirty people. So that was one problem. So the idea is, you've now got experience, you've got people who are like, that wasn't that hard, and there's more than one person, and now you've got cred. So this is one of the things he was talking about, the important aspects of what maybe talk about this was now you're like, we solve problems. So the next time you go to solve a problem, you're like, I have a resume of problems solved.

13:59 I solved this little one, then a bigger one, then a bigger one. So I said, could we take this to PT? What are the ninety nine problems? Let's rank them small to big. And then who wants to help me help me solve the smallest one? And we don't move on until we solve the smallest one. And then. We solved the next biggest one. But along the way, we picked up three or four more people who were like, I'll solve that problem. And now you've got a team who are now skilled at problem solving. They have a variety of skill sets and experience. The problem was, Alex, I put this post in. I said, help me figure out the problems. Nobody suggested one problem. So you have to remember, there's a couple of... problems with your problem.

14:39 Okay. I can't figure out what it is because I thought it was cool. A problem with your problem is that there's a selection bias. People who will react to that post are the people that are already problem solvers. You're probably right. Yes, yes. So you're not asking, like the problem solvers are the ones that will get a reaction out of it and the ones that actually do need to be the ones for solving problems are not the ones that are reacting. Yeah, I felt that trap. right right so the second one is like you're discussing thresholds right the threshold for change there's a really good book it's called cascades uh and the gentleman is a journalist and a uh i think political scientist but uh the point is he looks into the these environmental cascades that that are agents for change so essentially it's not linear uh change right and he talks about the eastern europe when the soviet bloc fell through and it didn't happen right away but initially there was a little protest and it was people who left then there was a little bit bigger protest and then the police instead of just letting people protest started reacting which caused even bigger changes so the cascade is that non-linear amplification of a response like a hockey stick until the certain and the threshold is past a certain threshold the cascade turns into change so what is the better question would be here is what is the threshold of stress on the system for the change to occur.

15:50 When is our community going to be right at that point? We're going to be like, that's it. We have to do something different. We're not there yet. Right now, we're still talking about problems. We're not talking about solutions because we're not at that threshold of change. It's not scary enough? It's not pressing enough? It could be scary, but we're okay with scaries, right? Scary is not actionable. Actionable is when I actually don't have Brad to feed my family. Then it becomes actionable. So when you, there was scary that was actionable was in two thousand two when Medicare came up with a cap and fifty percent of physical therapists lost their jobs. All of a sudden that was scary because you are not employable. You have your student loans and you have to pay for them. That is actually actionable. That's when change occurred. If you look at the fundamental change in our profession early two thousands was good.

16:32 Like we made a lot of positive change and then become complacent. Right. Then we have bread on the table. Right. I'm not hungry anymore. So. Oh, the line like, hard times create hard men, hard men create easy times, easy times create easy men. Now it's a cycle. That fable, right? Like it went to war, like came back. There's an entire Chinese fable that goes into that. Like each step of the cycle, there's a positive and a negative. But yeah, we're not there yet. So we're still just discussing this change. And we have been for years. Yeah. i foresee that the way the government is looking at our utilization matrix is they're going to try to cap our environment and we have a potential of becoming a very niche fringe industry unless we change and part of it is what we discussed about this risk-based contracts but part of it is just identifying that what you're doing is not good enough yet like it's it's good enough for you to satisfy the bare minimum now yeah when that changes you're in trouble unless you're prepared but the threshold of failure is based on your ability to handle the stress right like your your business resilience is dependent not on your execution right now it's dependent on how tolerant are you to when you fifty percent of your patient volume disappears can you still keep the doors open right or if the peers are going to turn away and say that you know we're just going to discount you another fifty percent and you're accepting these payments can you maintain that well and i think you can still operationalize it but are you ready i do you have these uh contingency plans and you're and you're prepared to until you're not and then you might not know what that point is but you'll know it when you get there the known unknowns and the unknown yeah like

18:03 yeah so these are known unknowns but you have to protect yourself from unknown unknowns you have to have enough of a buffer That allows you to be more resilient to these changes. Yeah. All right. We're doing quick live streams. And every episode we have, we do something called the parting shot. This is the parting shot. One last mic drop moment. No pressure. Just your legacy on the line. All right. Parting shot. What do you want to leave with people? What's what's either words of scary or words of encouragement? Which way are we going to go? Oh, this is a huge opportunity. It has been a huge opportunity. I think now we just have to seize that opportunity. We have a chance that there's still probably fifty percent of the market has not been captured by anyone.

18:45 Digital health providers came in and captured some parts of that market and now they have billion dollar valuation. and that's not even half of the market that's available if you look at the overall economic cost of musculoskeletal problems in a society it's a trillion dollar venture and we're capturing sixty five billion of it right uh so so the people who risk or the people who do the work who follow the last step give me the help me understand give me the checklist and follow the checklist will be the people who people there were the people are going to capture the other one billion dollars or one trillion dollars wow that is like it's it's just an immense financial and economic opportunity for those that are prepared yeah all right alex live from uh graham sessions appreciate your time thanks for doing this on your very first graham sessions amen thanks for being That's it for this one, but we're just getting warmed up.

19:35 Smash follow, send it to a friend, or crank up the next episode. Want to go deeper? Hit us at pgpinecast.com or find us on YouTube and socials at pgpinecast. And legally, none of this was advice. It's for entertainment purposes only. Bullshit! See, Keith? We read the script. Happy now?