What PTs Are Really Talking About: Burnout, AI, and Getting Paid

0:05 Broadcasting way too early from three separate Wi-Fi connections. It's PT Breakfast Club with Tony Meritato, Dave Kittle, and Jimmy McKay. Good morning, physical therapy and anybody else listening because your clinic Wi-Fi auto-connected by accident. Today, we're talking about three things that should be unrelated but are not. An AI company just bought another AI company. They're just eating each other. for a modest, two hundred eighty five million dollars in the grand scheme of things. It's not a billion clinics are growing while clinicians are well, they've got one foot out the door. We'll give you the numbers on it. Plus, Dave wants to put a fifty percent money back guarantee on patient care.

0:48 And if that made you uncomfortable, Good, because today's show is about who actually has leverage in rehab right now and who doesn't. Let's get into it. Tony, step one on having leverage is number one. You got to have confidence. Our sponsor today bringing you the show Confidence Spray smells like certainty. Today's show is brought to you by Confidence Spray, the first aerosol confidence booster for rehab professionals. Just one spray of foreign eval, and suddenly you sound like you know exactly what you're doing. Available scents include New Grad Swagger, Post CE Confidence, and the number one seller in rehab, Billing Certainty.

1:30 Confidence Spray, because confidence isn't learned, it's applied in a spray. Dave's jumping in there as well. There we go. Morning. I got my confidence spray on. It has nothing to do with billing, man. I just... I don't know. It's... It's like ax spray. You just a little armpits, a little on the chest, and then we're ready to roll. Nothing wrong with it. All right. We got to go with the big idea. I just did a little video yesterday. AI didn't kill PT. It just bought the front door. The news broke yesterday. It was everywhere. Sword Health acquires Kaya Health for two hundred eighty five million dollars. We said this. We were like, Sword's going to buy Hinge. Hinge is going to buy this. This is going to buy all these things.

2:11 We're just going to buy each other till there's, you know, this is the this is the Highlander. There can only be one. it's consolidation, right? This is about access, correct? This is not about exercises or apps. This is about access to people who's got the best Kung Fu, who's got the biggest bank account, and now they're working together. And I mean, thank God all the CEOs probably got paid, right? I mean, that's the bottom line. So what does this actually mean? What does this matter to the average clinic owner? Does it? Is it a signal? Is it a harbinger? What is it? You seem more excited than anybody about this. I didn't think anything of it. I saw the headline. I was like, OK, but you seem to feel like this has a bigger impact.

2:54 Well, I mean, we knew this was going to happen. Well, here's why. Here's why. I hear so much of this or see something with sword or hinge or kai or whatever. And then people are like, they use words they tell us never to use in PT school, which is never and always. Well, it doesn't matter what that's happening because AI will never be able to do what I can do. And we're always going to be. And people who use never and always, they typically don't have jobs anymore. So that's what I'm looking at, which is I don't think this is the thing. I think this is the thing on the way to whatever the big thing is. Okay, so before I hear from Dave, I asked ChatGPT and it said the big impact is market consolidation and digital MSK care.

3:39 That is an interesting keyword. We were talking about primary care, primary physical therapy care. Digital MSK care is something that probably we should do some SEO optimization for. Yeah. Significant expansion of reach, Germany and European market access, broader clinical and product portfolio, strategic growth signals and digital health, meaning it's looking good for digital health. Dave, what do you think? You know, I used to be more interested in the tech spaces, obviously. And I don't know. I just I don't think it's a big deal there. Like Jimmy said, it's yeah, you're just capturing more accounts and then they can try to cross sell the the either the consumers and or the decision makers of those consumers.

4:27 So the employee funded plans or whoever is offering Hinge Health. So if I'm sorry, this was this was Sword who made the deal. It was Sword that acquired Kaya. Yeah. whatever hinge hinge store whatever like yeah they're just they're just buying more users that they can kind of try to cross-pollinate with their core product and then they'll try to you know put it in front of the users they'll try to put it in front of the other decision makers at the other companies where kaya health was already ingrained in the companies using it uh i'm sorry what did uh dan batman say dan thank you for commenting live and being here Dan's saying it's about investors and debt. Same reason why Hinch help went public. It's about money. Sure.

5:08 Right. I mean, you only have so long if you've got whatever you've got. Right. And then if you know you're not going to be around two years from now, this is me making my best estimate. And someone offers you something and you're saying, well, it's the best offer we're going to get in the next three years. And if we keep going, we might be here in three years. You take the deal. You sell what you have while it still has value. That's my estimate. And I am by no means a big picture thinker like Dan and other people. Just I'm just that's not my thing, but I'm trying to understand it because I want to know what's happening for a clinic because here's what I see. I looked at, I don't know where the hell my phone is, which is for the first time ever.

5:48 It's not more. I don't, I don't think this affects brick and mortar or mobile or concierge clinics at all. Literally. I don't think that's my question completely. I don't think it'll ever affect how, how will it affect us? I don't, I have, I have, I have people that want the in-person experience, enough people in New York city that have enough discretionary income and I can pay my therapist competitively. And the people that pay us, uh, will laugh at this type of a platform then there's other people that maybe somehow they come they comment on hinge health and sword health's facebook ads and they're like this is cool and this is you know i get this through my employer and it's awesome like that's amazing like cool where are you where where are you where are you this is a bell curve where are you are you in the middle where is my practice or what do you mean what do you Where are you?

6:35 Are you in the middle? Yeah, your practice. In terms of average, if this is beige walls. Average of what? Of using tech? In terms of usage. Like, where are you? In terms of if this is an innovativeness bell curve. So I think I was telling you guys about the AI recording sales apps and that type of stuff. So I'm always an early adopter in testing things out. But in terms of our offering of our practice, we're on the opposite side. We're on the small end. Let me ask this a different way. Are there more PT clinics in strip malls or more clinics like Dave is doing in New York City?

7:16 There's more clinics in strip malls. Right. You're over here. I'm asking what this is going to do for them. Nothing. Nothing. I don't know, man. I don't think it's going to do anything. All right. I saw this. I disagree. I agree with Dave in the sense that it's not going to affect him. It's not going to affect me. But to me, the middle of that bell curve that Jimmy is showing is Athletico, ATI. It's the large, multi... It's something like Kaiser Permanente. It's these big groups.

7:58 I do think they will see an impact. I do think it will draw out a lot of the excess in referrals just because it's a cheaper, easier solution. Back to what I said, I think, the other day. I don't know. If I'm going to waste money, I would rather waste less money than waste more money. If I'm going to pay for somebody to go get useless therapy, I would rather pay less for them to get useless therapy. That's what I'm saying. And those are the referrals that I think we're going to see sucked out of the market. It's not going to affect you or me, but it's going to affect those large organizations that are dealing with thousands and tens of thousands of CPT generating machines.

8:41 Ben thinks it looks like a mustache from a guy in the eighteen hundreds. Come on. Ben's smart enough to know he knows the bell curve. He's just joking around. He knows. Dan says it won't affect us yet. The longer these doors exist, the more it will change behavior. That's what I'm saying. I saw this in two thousand and eight. And I started walking towards the door out of radio. I understood that it's crap. Do you guys remember the term buffering? It's not even said anymore. Like there was a thing, kids, there was a thing called real player. That's how you listen to anything on the internet. I listened to my first live stream in a car with my phone plugged into an aux cord, driving home from work.

9:23 And I was like, this sucks. But in six months, it's going to suck less. I could not have convinced anybody to listen to a crappy live stream on a flip phone in two thousand and eight. I'm saying in ten years, what will this do? I don't know. That's what I'm worried about. This is probably going to affect a middle schooler right now. That's what I'm saying. The middle schooler who's like, I'll be a PT, the middle schooler who just tore her ACL, who's like, I'm going to go to be a PT. I'm questioning that. That's also going to sound smart, too, is just say your idea is going to be thirty years in the future and then you're not around. You're not around to defend it. A couple of things that my GPT said that I thought was interesting.

10:05 It it's saying that Hinge Health still is by far the market dominating company. It said that Hinge is more positioned for wearables, which I didn't really even think. I don't know the difference. Yeah, basically it's saying Hinge is more about wearables. It's got a larger U.S. member base, larger investors with the IPO that's happened. Sword is just trying to kind of gain market share, but it's not even close to what Hinge is capable of right now. Hinge has the connections with the employer base and the payer base. But it keeps bringing back this thing about Hinge being connected with wearables that Sword doesn't really do.

10:52 And Sword has apparently more of an emphasis on live clinician interaction that Hinge doesn't necessarily do. We briefly talked about this a while ago about some of these companies sending like a wearable device to someone's home so that it can track their repetitions, the range of motion, whatever. My stance on this was that's ridiculous. And in general, over time and across the country, People are not going to just like there's these EMS suits. Have you seen these EMS full body suits with electric EMS electro simulation? And I talked about it. There are personal training companies doing it.

11:32 Yeah. It's people get sore afterwards. People say it's a great workout and that's fine, but there's so much to put on. It's like, it's literally like you're going to have a wetsuit on. Like you're going to go, you're going to go, you're going to go surfing right now in, you know, it's like a wetsuit with EMS and all these electrodes and it activates your muscles or whatever. So it's like this big new, you know, trend in personal training. But that's just too much. You're sweating into it. Now it's got to be hard to get off because it's wet and tight. It sounds like a horrible... Sounds like a good Friday night to me. We had one client that has tried it. One of our physical therapy patient clients has tried that, and they liked it.

12:15 But in general, it's just too much of, I think, a new thing, too much stuff to do, and even a wearable... like it's just it's just not the right thing i remember i poo-pooed the wearable thing and i got tony's approval he you agreed with that that's like not the no like just like a wearable like a i don't know like a wrist thing or a leg thing or something like if hinge health or sword health were to send yeah to every knee pain patient or whatever yeah if it's not a thing i'll just normally like a watch like if it's not going to do another thing i don't think people will do well i don't know there will be the edge people i mean because people are wearing whoops the rings, there's also a little psychological signal there.

12:56 You know what I mean? This is why I get the Iron Man tattoo. It's like, I want other people to see it. You know what I mean? It's a little bit of that. If you're at home doing your knee exercises with a wearable through hinge or sword or whatever in the future, no one else is seeing that. Yeah, if you take some social media video, you take a video of it and you post it online. If you're a true patient that's like, it's a different wearable. It's outside of your normal things. Like you're saying, Jimmy, it's not a watch. It's not a normal thing. And so I don't think there's going to be long life of those wearables regardless. Ryan Eder, I had him on the show, I think, and I'm going to have him either just out soon.

13:39 He's big into computer vision. You're not going to have to wear anything. Like you're going to wear a watch for like the biometrics, but like in terms of range of motion or like all those things, it'll be a camera that you won't even have to think about looking at you to measure all those things. Like we're not, it's there, we're here. Hey, if regular exercises fixed all orthopedic and musculoskeletal pains, then we would never get referrals from personal trainers. Personal trainers would be just fixing aches and pains and chronic pains and all this forever. So again, I will stand on this, that this hinge sword health stuff is short while it's here. It's not going to be long lasting.

14:21 We talked about it before, but for people that benefit from it, that's amazing. That's awesome. And if you don't need to pay out of pocket or you don't need to do a copay and go to Tony's office, whatever, that's great. That's fine. But then you're going to have questions and you want to speak to a specialist like Tony that has experience. And you want, again, then you get sucked into the environment and the cheers experience and the office and all that. That forever, I don't care what technology... improves and changes over time the experience of either the one-on-one what we do or the one-to-many in tony's office with that environment is what people will want for millennia in my opinion regardless of any technology You know, I think it's interesting.

15:02 In my clinic, I would basically say, and this is like Midwestern steel town, you know, it's not where Dave is. Most of my geriatric patients have a smartwatch. Most of them get alerts and messages, texts and all that stuff on their smartwatch. I was just looking at some numbers. So Apple, obviously the biggest smartwatch distributor, Hollywood. uh, two hundred and eighty one million million units sold as of two thousand twenty four. However, Apple Watch shipments declined nineteen percent year over year in two thousand twenty four. Personally, I don't think the market is in wearables. I think the market is implantables.

15:45 We have patients getting total knee replacements where they're they have the technology in the implant so that they can measure range of motion, they can measure step counts, they can measure that stuff. We have patients with the watchman implant, you know, pacemakers like smart devices that are in your body. I really like this is now getting to the point where it's not like you forget to put your smartwatch on. I never wear a watch. I hate watches. I don't wear jewelry. I don't have a necklace. I barely I wear my ring. That's about it. But putting it in your body, I think that's where this is going to go. Yeah. I mean, guys, look, X-Files and those sci-fi shows from back in the day, it's amazing.

16:30 There was an episode... Were you guys X-Files or am I the only... Well, let's go back. We'll come back to that for one second. No one's going to get implantables for normal physical therapy though, Tony for, for a surgical procedure. Sure. Okay. Let's say in the future, every surgical procedure, you implant something that's going to then track their range of motion or their cadence. They're walking, they're standing versus sitting rate, whatever. That sounds super cool. Like that makes a ton of sense, but how many knee replacements are done in the country per year? Like a couple hundred thousand. Over eight hundred thousand, I believe, in the US, most of which is which is which is typically overdone, like in other countries. But that's the thing. Like, I don't think I've seen a patient come in after their first knee replacement who didn't book their second knee replacement six weeks in the future.

17:17 Every single one of them is coming in. I'm bone on bone. You just walked across the room fine. But yet in their mind, they're bone on bone and can't function without a second knee replacement. But that being said, like, take this through the next logical step. OK, so we've got smart devices being implanted right now. Why wouldn't there be a knee replacement that does the exercise for me? We had a passive range of motion. Like now we're going to be at the point where we put a knee replacement in that does the range of motion for you. You just measure it. You skipped ahead. I thought you were going to say implant the knee that can measure use and range of motion.

18:00 That's already there. The knees are already there that measure step count, that measure range of motion. I didn't know that. We've got that in the clinic right now. They have the app on their phone next to their electronic knee. Why not have the knee that walks for you, that does your range of motion, that stimulates the muscles, that has EMS in it, that makes you whether you want to or not. It's going to need some really big chips from NVIDIA, and they're probably too big right now to fit inside this knee replacement. For all the stuff you're talking about, for EMS. Yeah, but those are smaller. But in terms of like an EMS and to make someone get up and move. And can you imagine a patient that's like sixty eight years old and they're like, I don't want to move.

18:42 And their knees like making a move and they're like having to stand up. I don't want to move, but the knees moving anyway. What are you going in for for surgery? Ah, they got to replace my knee replacement. They got to update my iOS on my knee replacement. And that's, you know, they got to do, that's a hard replace. They got to plug, they actually got to plug in. Ben said, there's a company doing this. And frankly, the data you get, it's not worth the cost yet. There we go. Ben, I'm going to say yet after all of that, you can get most of the same info. Yeah. Unintended consequences. Absolutely. Yeah. Well, I mean, somebody in the comment section below, right?

19:22 Whenever you start talking about this stuff, you start talking in logic and people respond with emotion. It's human nature. I'm guilty of this ten times a day. People will never, AI will never, robots will never And I just say, yeah, like it will never replace. This is where like now you go the other side of the pendulum, which is like it will never replace our hands or our minds. And I'm like, I don't know. The AI robot has entered the chat. The AI massage thing has entered the chat. I don't think it will replace things. All of those things. I'm asking how much of the mustache. will it will it capture it always affects the middle first that's the financially the best place to go for and it's the easiest place because beige painted no no it's the it's the it's the innovators first which is the smaller one side and then the middle is like uh mass and then the other side would be the laggards what i'm saying is the the early doctors innovators and then the middle is the mask go ahead Right.

20:23 I'm saying any innovation in terms of population, who's most susceptible? It's not Dave or Tony who have innovative anything. Who's most susceptible to innovation? The PT clinic who's got beige painted walls in a strip mall who hasn't innovated in twenty years, they will feel this punch first. We're going to talk about prompts report. The clinic that's about to die will be affected by a two percent change in something like this in three years. You guys won't. It's not even a speed bump. This is a gnat on your windshield. This could cripple the ones that are already circling the drain. They're the most susceptible. The ones that either have... Yeah, it could be.

21:06 The ones that have slim profit margins and or lower perceived value from their average professional client. That's what I'm saying. But what I was saying a second ago is people will say, well, it'll never be able to do this. It'll never be able to do that. And I understand that. Except all it takes is... two percent of anything and that ram the ramifications that math maps why are we looking at what is that wally wally i mean for for decades i assume the future of humanity was this but for the first time ever I'm realizing like we've got the weight loss drugs. We've got the technology to force people to exercise whether they want to or not.

21:50 We've got implantables, not just wearables. I really think we could be at a tipping point here where whether somebody wants to. I was just listening to an interview where they talked about removing memories from your head. So if you wanted to take a memory out, they could find it. They could zap it and it's gone. Eternal Sunshine. It's a scary time. It's a scary time. I'm not denying it. That could fix some mental health. There might be some good use cases there. That's a movie. That's what I was going to say ten minutes ago. There's an X-Files episode. The entire episode is shot in a sushi restaurant with Dana Scully and Fox Mulder.

22:31 No humans... are involved you order with an app it's a sushi right you order with an app and then there's machines in the back and there's a problem of course with with molder's order and then it's it even keyed on the tipping how much do you want to tip and molder was like no tip and the app was giving him crap all that was ridiculous ten years ago when that thing came out it's not ridiculous anymore do you guys have this The shopping cart at my supermarket right now, I'm not even that edgy. I'm not in a big city, right? I'm an hour from New York. Dave, have you seen this? Shopping cart.

23:11 I log in with my price plus number. And then as I put things into the cart, I just swing it by the scanner and boop in there. And when I check out, it already knows what's in the cart. Here's the kicker. If I put something in the cart and didn't scan it, it's like we have a camera. We watch something go in that didn't scan. There's an error. We're going to have an associate come over and check that. We're there. This is in upstate New York. This is not the edge. Guys, are we going to be beaming people up? I mean, everything in Star Trek has happened. That was Nextel, right? Laser beams. We've got those things. It's just time.

23:52 It's time. So to Ben's point, yes, meat sacks. We've used that terminology before. I just want to be a muscly meat sack. I want muscle, not fat. I love the one line in The Matrix, though, where they're like zinging each other and called them copper top. And I think that went over my head the first eighty six times I watched it. And I was like, oh, it's a battery. That's an Energizer battery. Copper top. Oh, Duracell. Duracell. Yeah, I don't imagine. I mean, this has probably been one of my biggest friction points. So Ben says, even setting up your phone for computer vision can be a friction point.

24:33 I agree. Thinking that somebody is going to set up a phone and record them doing videos and the AI is going to analyze your hip hinge and is it proper? I think that's a total waste of time. I don't see any reasonable person doing that. Oh, no, no, no. The first people will be not reasonable. These are the people who already own tonals in their house. I was talking with someone who I love her. It was like, I think people should just, I mean, wouldn't it be great? You'd save a lot of money, just buy a tonal. And I'm like, what does a tonal cost? And I can't remember what it costs, but I remember thinking, are you insane? What does it cost? I mean, at least hundreds, if not a thousand.

25:16 This person had money and they were like, just buy tonals. If everybody got a tonal and then a PT could zoom in. And I'm like, lady, you are so far away from reality. We're not all, we don't have tonal money. But as that goes on, that's going to get cheaper. So I think the people who have that might be, wouldn't that be a great model? Instead of just doing telehealth with a phone, you zoom in on a tonal and you're staring at them and you can know, okay, do this exercise, boop. And then just like the matrix, do you know how to fly a helicopter? Now I do. Okay, do this exercise. And the tonal changes to the thing and gives the proper resistance. That's the merging that I'm waiting for.

25:56 We're not there yet because tonals cost ten grand. So, Jimmy, you had two other topics. Let's get to topic number two. Yeah, we have to get to topic number two, but we also have to talk about another sponsor. This one... This one could be a thing. This one's already a thing. I would do this one. Students love it. Clinicians love it. The clipboard of authority. This segment is sponsored by the clipboard of authority. The heavier the clipboard, the more correct you are. Perfect for nodding silently, pretending to observe movement, and ending conversations without speaking. Just look at your clipboard. Now featuring extra weight for difficult patients and premium leather grip that says, look...

26:39 I've been doing this for a while. The clipboard of authority. You don't need answers. You just need something to hold on to. That's all you do. All right. So very low, very low, very low tech, very low tech, very low tech. Like it carries a little cachet in it. You know, I was what I want to brag. I was a VIP. Did you guys get this? I don't know. I'm a VIP. I got something very exclusive. Probably only fifty people in the country got this. I'm only kidding. I'm on the prompt mailing list or whatever. I got this in my inbox and I was like, what's this? WebPT has done this for years. It's a state of the union. Because if you're an EMR company and you have access to hundreds or thousands of clinics, why wouldn't you ask all of them for a survey and tell them, we're going to put all your answers with other people's answers and we're going to get answered answers.

27:25 So Prompt Health, twenty twenty six rehab therapy report. I got to be honest, I just started calling it the state of the union because rehab therapy reports didn't have any pop for me. Eight and ten clinics are growing year over year. Seventy percent of clinicians are thinking about leaving. I don't understand that. Eight in ten clinics are growing year over year. Seventy percent of clinicians are thinking about leaving that clinic. Burnout highest in clinics with disconnected manual systems. Younger PTs less than thirty are most burned out. I'm just throwing out statistics. What are these things? Do the data ever shock you guys from these things or just like, yeah, we knew that?

28:05 Before we talk about the data, before we talk about the topic, For the folks at home watching on YouTube, Jimmy wore a tie to make this video on PT Pinecast. And I just want to reflect on the power of Jimmy's diverse attire. Sometimes it might be a hoodie. Sometimes it might be a beanie. Some days... He's got the hair done. Some days he's shaved. Some days he's not. Some days he's got a tie on with a white button up. I couldn't believe it. And I was never sure, like, who would wear a tie on a podcast first. I mean, you know I'm close enough some days. But I thought, you know, would it be Jimmy? Would it be Tony? No, definitely Jimmy.

28:46 If we're on Kalashi or whatever that app is where you can bet on anything, the number for which one of us three to wear a tie. I was the, I was the long shot, but you paid out if you, if you voted on that. Cause I wanted to do like, I was trying to find like serious, like I totally get it. It made sense. Music or whatever. So when you guys look at these things, You know what? Do you look at these things? If you do, does it surprise any of you? Or are you like, yeah, okay, I figured that. Or is it ever like there's one statistic in there that goes, huh, didn't think of that. I was surprised when APTA said we were going to have too many physical therapists. I remember that.

29:26 That was a while ago, right? Seriously? That was a while ago, right? Yeah, yeah. That was an old report. Right. I haven't really been looking at these market reports. I think at this point, the past, I don't know, before and even before and after COVID, they're kind of approximately the same. I think still one of the best ones is that the WebPT one about the drop-offs, which was like, I don't know, whatever it was, like, uh, ninety percent of patients drop off or something, something insane that don't, you know, don't complete their plan of care. I think that was probably one of the best ones from, like, the past I don't know, ten years or whatever. But everything else, I mean, prompts is obviously going to be most of this data is going to be from in-network clinics.

30:09 So that's fine because that's like where the volume is. But most of what you covered, like I watched a little bit or I listened to a little bit. So I wasn't surprised at all. Yeah. Well, the things that the contradiction is confusing me. Eight out of ten clinics are growing year over year. except seventy percent of clinicians are thinking about leaving which means the clinics are doing well but they're just shuffling and reshuffling the deck they could be i don't know couldn't wouldn't that say a clinic could do a lot better if you if you stopped having to try to attract and hire people sure yeah you would have more focus on know marketing or growth or stability and less focus on recruiting and hiring i mean you always need you always need to focus on both but if seventy percent of your workforce is whatever it was unsatisfied or looking to potentially leave the leave their job or leave the industry like yeah that's quite significant I liked Jared Hall's recent post where he was talking about, and I forget the law or the rule, but basically as you make things more efficient, you increase utilization.

31:17 And I think that's what we're seeing here. Clinics are operating more efficiently. They're getting more done with less staff. I just that's it. That's there's no other like secret recipe. Yes. More therapists are leaving. Yes. Fewer therapists are joining. We have to develop business models that don't look like the business models of the past. Why are we in the insurance based market? trying to do what Dave is doing in the self-pay market. Why are we still trying to do hour-long sessions? Why are we still selling relationships and listening to stories when that's not what we're being paid for? Everybody across the board goes to single-unit visits.

32:00 Immediately, we quadruple our access to clinicians because one clinician can do the work of four if we reduce the duration of the visit, and I would argue the patient gets a better outcome. The patient gets a faster outcome. How would you define a better outcome? if it was all single unit visits? I don't know that I would say faster. In other words, my shoulder hurts, now my shoulder doesn't hurt. Do I get to that end game faster? Probably not, because we're talking about healing tissues, we're talking about physiology. But I would say better because the fifteen minutes, ten minutes we spend with each patient is more impactful.

32:41 They actually remember something we taught them when they go home. We increase compliance if we increase frequency. We reduce total utilization per case, but we increase the number of cases. Like every metric goes up in a positive direction if we treat this in the way that I believe it's intended to be treated. Meaning... What's your problem? This is the solution to solve your problem. Let's start working on that solution. Doesn't have to be what's your problem. Let's get to know each other. Let's spend sixty minutes of uninterrupted time in a private room. Tell me about your deepest, darkest fears. I like to know. If you, if you, if you had a, if you had an orthopedic issue, right, you had the friends PT clinic nearby down the street, which, which, which one just for you, like, which one would you prefer?

33:29 Like you go to his practice two times a week and each time is an hour or Tony's saying you go in for, you go into Tony's version of the clinic that is also in your neighborhood or in your town. And Tony's off. Tony's offering what? Fifteen minute visits. But he's saying come more often. Yeah. So I'm saying I like both of those. I'm going to smush them together. Here's what I would want. I would want the initial eval to feel like you're measuring me to be an NFL wide receiver. Like I'd want the eval to be like, let's check everything. Let's really get to know you. I want to find out follow up visits. What I would prefer and I think people would follow would be.

34:11 Hey, buddy, let's check it out. Let's chop it up for ten minutes. Let's do all those things. And then here's your thing. You've got access. You can leave now or go do the things. I'll give you six things to do. Do them or not. But that's not one-on-one with the therapist anymore. So I would say the eval would make me feel like a full diagnostic for one hour. And then follow-ups would be, let's see what we did between last time and now. Good, based on that information, do these things. Steve over here is going to help you. And then it's a one unit visit plus access, use it or not. I make suggestions, you make decisions.

34:51 Wait, so you were saying, so Steve would be, what's the example? So the therapist is with the patient for fifteen minutes. You said go over to do whatever with Steve. Right. Yep. Attack or whatever. Right over here. Here's the thing. While I'm talking, look at Ben's comments. Which one? Yeah. So Jimmy wants to feel important. The evaluation. He wants to be measured. He wants all these fancy devices. And I totally agree. When I go to Chipotle, I want filet mignon instead of cheap flank steak. But when they show me the price of paying for filet mignon, I choose the cheap flank steak. Right. Have that available. And that's why you will never go away, Dave, because you offer the highest level.

35:35 It is available, but you're not trying to do it for insurance reimbursement rates. So give the consumer the choice. Hey, look, I can fix your shoulder pain. Dave can fix your shoulder pain. Mine is going to be covered by insurance. Dave's not. Dave will have more fun. Dave will have a better experience. Dave will have better products. I will not. But both of us will get you there. It just depends on how much money you want to spend. How do they want to get there? How do you want to achieve your goals? Yeah. What I would say is to keep the feeling high or mid, you know, six, seven, I would do the one-on-one bougie eval, right? But we do that now and we can charge for it. Even insurance companies will say, yeah, the eval is more work, so we're going to pay X. And then...

36:21 Subsequent visits and all the different policies are lower. I would say to keep the same perceived value because all value is perceived value. Keep the one on one. Everything's about you. Let me look deep into your soul and learn everything about you. That's the eval. And follow ups are a one unit plus, though, instead of one unit. And then, all right, here's your code. Get out. Let's do the thing. You know how this is going to change. Not me touching you. I did the thing. I did the rubbies and I did the tuggies. Rubs and tugs. And now go over there and get sweaty. What do you want me to do? And then have access to the cryo pool and the infrared spa and the light you'd stick somewhere. Do whatever you want, but it's access and you don't nickel and dime them for that.

37:04 I think that's how you keep your perceived value high while keeping your costs low and go more on volume. I'm going to pull this up. Sorry, I'll do it. All right. So Ben said, let's pause there. And this was a little earlier in the conversation. If drop-off is so high, reimbursement is so low, where are the companies like Ash who regulate PT visit utilization when the reality is PT is a rounding error? Agreed. Does that mean you know it all as a whole? The cost and pain of utilization management is not needed as most patients drop off before even hitting the seven hundred dollars in billing.

37:45 Why does this still exist? What does that mean? It's a rounding error. You said you agree. I don't understand that means. Yeah, it's very it's very small in the whole scheme of things. You look at the total cost of health care, you look at what we actually I mean, a thousand dollars is like ten visits compared to, you know, surgeries and anesthesia and ORs and all this other stuff. The only thing I can imagine now I'm speaking completely out of speculation and Ben can correct me. I would imagine these companies are coming to the payer and saying, look, it's not going to cost you anything. We'll take a percentage of what we save. And so even though it is such a tiny amount, if they come in and run their algorithms to say this patient needs four visits, not thirty six visits, they save the insurance company, they're going to get a portion of what they save.

38:32 Why wouldn't you do that? That's why I think they still exist. And then Ben said, in fact, if PT was better utilized without friction and reduction in TCOC, Total cost of care and musculoskeletal as a whole goes down, putting friction in the wrong spots. And that's where a couple of weeks ago I shared it. I asked chat GPT. I'm like, if there's all this research that says we save insurance companies money, why are we not seeing the benefit of that? And it's because most likely the insurance company business model does not benefit from what we do.

39:14 If we maybe and I don't think we actually do save the insurance company money, but if we did, they're making money in other ways. They need to spend more money, my understanding, in order to make more profit because they're limited to a percentage of like the money they spend is how much they can take as profit. So it doesn't help them to spend less. It's better for them to spend more because then they can charge more than they can profit more. That's that's the model. Yeah, I mean, this is where I love people who do advocacy, but that's not going to change it. I mean, guys, let's be realistic. It's not like insurance companies don't do math. They're a math company. It's all they do is math. And if we had a big enough math, they would math with us.

39:58 And they would go, here's more math. I'm using math as a verb and a noun. That's not it. I'm very sorry. They don't under... What's that line I just used like seven times? The Upton Sinclair line. It's hard to get someone to understand something when their salary is dependent on them not understanding it. It's not even that. We're so small. It's like, oh, are you still here? Did we? Yeah. Okay. Yeah, sure. We'll give you a nickel. This will go down. Reimbursement will go down. year over year. Act as if. Decide if you want to be in this. Since I released that video when I went to Graham Sessions last weekend, people were like, I loved it because I just sit here. They're like, well, what are you going to do about it?

40:38 What's APTA going to do about it? I'm like, guys, I'm a dude in my living room. Sometimes I wear a tie. What am I going to do about it? I'm asking you questions. The people who want complete control are also looking for people to solve it for them. And I'm like, you still have to solve it. What were you going to do yesterday? Nothing. I just held up a mirror and you're shocked at the result. I'm very sorry. That ain't it. Go ahead. Keep the conversation going. I'll be right back. Ben Galen saying population health principles deliver the solution cost that matches the severity and need. Yeah, not all patients need the filet mignon. They don't and they won't buy it. That's why it's a pyramid.

41:20 What I mean by that is what Dave does is higher end, quite literally up on the pyramid. But the pyramid, we know how pyramids are shaped. It's thinner up there. You're not looking. You don't need twenty thousand people. You need two thousand people or a thousand. I don't know. So you're like, I'm going to solve this, which is funny. when Dave talks about what he does and people respond, Dave says, emotional, sorry, logically, I do this for this cost for these people. And then I've seen this happen in Dave's comment section. People are like, but what about people who can't afford it? And like, I don't know. It sounds like you want to take care of those people. I think Pete, all people should have access to care.

42:00 I agree, but it's not going to be the same. I understand that. Exactly. Exactly. Why not cake for breakfast and lunch and dinner? Then we'll want cake with triple frosting. This is a choice. I don't know how else to explain. This is not me deciding this is the way it is. This is the way it is. I'm just the one explaining it. Don't kill the messenger. But if you want to drop it in my comment section and increase the reach, by all means, I'll poke the bear. I will do that. Yeah, I mean, there's a bunch of practices that accept Medicaid and Medicare and all the different payers and insurances. But if those patients wanted a more one-on-one experience, that clinic cannot offer that, right?

42:46 But we can, but therefore we can't accept those low-paying insurances, right? So no clinic can offer everything to all consumers in terms of like each little subset, like physical therapy or whatever the other industries are. So Mark, I don't know, Mark and his comment is APTA has to cover all PTs. Stop. What does that mean? Cover what? Cover what? They're a professional association. They drive across a bridge and talk to people in Washington. What does cover all PTs mean? Cover them how? They don't dictate rates. They don't dictate educational requirements. That's CAPD.

43:26 They don't set tuition prices. Yeah. So I know Mark, he's been on my podcast. He's got a practice on the West Coast. I think maybe he's saying that ABTA is like representing all PTs and it's hard to represent all PTs when there's different sections of PTs that like want different things and all that, right? Agreed. Agreed. Here's the thing. None of those things are going to happen. They're not. It's a professional association. This is a place to hang out with people who do the same thing as you and learn what's working and what's not. Don't look at it as big brother. It's not. It's not big brother. They don't sell themselves as big brother. I wish they were. I wish we could just throw a bucket of money and they'd go across the river and solve things.

44:06 They can't. If they lowered the reimbursement for us, that would hurt another set of PTs. Who is they? Insurance companies, if they lowered the reimbursement for us, I'm guessing inpatient PTs, is he an inpatient PT? No, he's got an outpatient practice. So Mark, thank you for joining us live. Give us another comment or two, Mark, if you want to just help clarify a little bit and we can keep rolling. John thinks we should get Ben Galen on the show because for a deeper... I've threatened that. I've said Ben. I think Ben... Yeah, he's been on my show. He's super smart. This is when you know someone has something.

44:47 Because I think I DMed Ben, or maybe I did in my head, and I was like, hey, I think it was one day when one of you guys was going to be out. I was like, hey, do you want to... And he was like, oh, I don't really have anything to add. I'm like, really? Because... you add a lot like maybe just add it without text without your thumbs doing the talking um i want to understand what mark is saying because i hear this a lot But I'm a words guy. So when people start throwing they or cover, I'm like, cover what? Cover how? Cover who? What does that mean? I want to understand. Because I think this is an expectation and reality problem. People are like, I paid five hundred dollars for my APTA membership for a decade and I didn't get anything for it. What did you expect to get?

45:30 What was on the menu? They didn't offer that. You felt like they did, but you didn't read it. I don't think you should be an APTA member unless you understand what you're buying. And then if you don't like that, don't buy. People think I'm the biggest APTA whatever. I'm just here explaining stuff because I hear these people saying the same complaints and I'm like, what did you expect was going to be in the box? I don't agree with Jimmy working on my statement. Okay. This is where a guy like Mark, I want to hear his words because most of the time when I see that, we wind up, we're agreeing, we're just using different words. Yeah, he does. I'm not taking shots. What do you mean by that? We're on the same page.

46:12 Ben's got the face for radio. Keep talking, my friend. I got the face for radio, too. Let's get to this. Hold on a second. Oh, gosh. These guys paid triple the rate. Uh-oh. There's a big spender. A big sponsor. This is Triple the Rate. Clinical Vibes, this section brought to you by Clinical Vibes. Brought to you by Clinical Vibes, the treatment philosophy based entirely on how it feels. By the way, all the visuals today, I used Tony's prompt. No protocols, no guidelines, just vibes. Simply ask yourself... Does this feel right? If yes, document confidently from then on out. Clinical vibes, not evidence-based, but emotionally compelling.

46:53 All right. They paid triple, but did they pay in cash or vibes? They paid in vibes. They paid triple the vibes. It felt like a good deal when I signed it. I like the, like when Jimmy reads through like the little, like the real advertising. Oh, he froze. What are you going to give me a compliment? What happened? I'm here. You don't hear me. yeah yeah i'm here you're good you hear me yep i'm good now we're here go so when you read when you when you read through kind of like the bullet points of the advertisement like from chat gbt or wherever you got it um it's it's perfect i love it i think though in the future we should consider you put an ad up and tony or i have to do the ad read completely i like that idea Cause we never know what's coming.

47:37 I don't, I don't know if the audience knows, but so you do these, you put them up. We have no idea what's going on on the screen. No. Yeah. What I want. It's not going to be, the ad read will not be as good as whatever you usually read. So you know what I want to do? It could be a fun exercise. The worst part of this, and I need to adapt, the worst part is when I put the ad up, I can see your faces in the monitors, but the audience can't. And I see you reacting. So the funny thing is I'm looking at you guys, but the audience can't see you. And when I see one of you giggle or do this, I go even harder. Like I go full Phil Hartman on the next line. And if I look at you guys and you guys are like, eh, I sort of just speed through it. I'm like, I don't give a shit about this. Well, let's keep moving.

48:19 All right. Anyway, Dave's going to sell certainty, not sessions. We're going to call this the fifty percent guarantee experiment. Dave, you run with run with us. Okay. Yeah. So I want your feedback. We're doing this live. This is what I would usually do with like my friends or business coaches or whatever. So we're kind of like five fifty a visit for Saturday, Sunday, three fifty per visit, Monday through Friday. That's kind of like our pricing. We do take some insurances and all that type of stuff. But Um, I've been reading more. I had the a hundred million dollar model, whatever money models from Alex Ramosi. I got a bunch of, I got a bunch of stuff from Alex Ramosi. And one of the things is a, you know, there's money back guarantees or there's conditional guarantees.

49:01 I want to pitch this live. So just, let's just say, um, Say Jimmy's got back pain. Jimmy's got seven out of ten back pain. He's got pain when he squats and Jimmy wants to get back. I'm just making all this up. He wants to get back to Orange Theory Fitness. He's going three times a week, but now he's got back pain with squatting. So Jimmy comes in. He does an evaluation with my physical therapist, Dr. Andrew. In that visit, in the first visit, he goes through the whole one hour comprehensive evaluation, pre post test, all that. The pain goes from seven out of ten to five out of ten with your deep squat. So, OK, let me see a squat. And you're like, oh, yeah, right there. It's seven out of ten. And then we do some treatment, whatever the treatment is.

49:42 Then, OK, let's stand back up. Let's squat again. Five out of ten low back pain. So you're already having a treatment preview in a short period of time, which will then help the therapist then present financing and cost and investment, all that type of stuff. So then the therapist says, all right, Jimmy, so based off of this and how you're feeling, I believe that I can get this better in twelve visits. I think there's a good chance that I can help you completely overcome this. And in twelve visits from now, we'll talk about whether we're going to do once a week or twice a week or whatever. But with twelve visits, as well as some things for you to do at home, I'm going to get you back to Orange Theory. So I'm selling your goal.

50:22 I'm selling the outcome, the transformation, the result of what you want, which is getting back to Orange Theory. And what we're going to do is to get you there. What it's going to cost is forty two hundred dollars. And so I meant just multiplying. So three fifty times twelve is forty two hundred dollars. And you're going to be like, oh, my gosh, that's a lot. And I wanted to use my insurance and all the normal objections that we hear. And that's more than I thought it would be. And I got to speak with my spouse and I got to think about it and sleep, sleep overnight on it and get back to you and let me think about it and all that type of stuff. and then we would say okay well we want to nail down is it just price and let's just say if it is just price it's literally like you're fearful of paying something and not getting the outcome you're you're afraid of paying for something and it not working right so then you feel like You know, you feel bad about yourself.

51:19 You feel like you made the wrong decision. So then we say, hey, Jimmy, if we do not get you back to Orange Theory in these twelve visits and we could do video and we're going to make it objective and measurable as much as possible in terms of like squat depth or we want to just try to make it as objective as possible. And you have to do some check ins along the way in terms of showing us some exercises that you've done or whatever it is along the way. So you have to hit some checkpoints along this twelve visit process. you're not paying free by the twelfth visit you get half your money back or you continue to we'll continue to work with you until we get you back to orange theory and then there'll be some terms and a little bit of fine print about what that would be is it going to be like full normal visits or is it also remote coaching remote programming whatever but there's a little thing a couple things for me to iron out there but it would basically be like Now, it's not a hundred percent money back guarantee, Jimmy, because we're going to do our side.

52:17 Like we're bringing our A gain every single day and we need to make sure. So like we can't refund that because it's like a service based business. So I can't refund a hundred percent of your money, but it would be fifty percent. So meaning if you if if it didn't work for you because you didn't trust yourself or whatever, we'll refund half your money. So you get to the twelfth visit. You let us know, hey, I want half my money back and we send you two thousand one hundred dollars back or whatever. continue to work with us in whatever the defined capacity is moving forward and i think that the issue or the challenge of this for me to wrap my head around is like would some people like refunding half the money is fine but tony what if someone was like no i'm not a hundred percent but they like wanted to stay working with us like almost indefinitely i think that's like my only my only thought of like how this could ever go wrong like someone who wants to work with us for another twelve visits.

53:09 And then like they say, they're still not better. And then they're like, actually, just refund half my money. So now they got twenty four visits and now asking for money back. So there's some things around there that need to be tightened up. And this is what I would like your help for or help on. Tony, you want to go first or me to go first? I don't know. I hate it. I just don't like it. You know, I think about so many professional services. I think about like attorneys. You're you're indicted for something, whatever. Like the attorney is not going to give you fifty percent back if they don't. If you go to jail, there's just so many things like that. I feel like this makes it too much about the money. And if we're coming down to, and I shared the risk reversal definition, I just think we're focused on the wrong thing.

53:54 And for you and what you do and how you do it, I'm just not a fan of this kind of interaction. Yeah, I like it. Here's why. But there's going to be an asterisk everywhere. There needs to be specific and asterisks. Here's what I mean. Number one, this is not for everybody. You tell your staff, define who this is for. This is for the person who that's their primary objection. Like what are you afraid of? I'm afraid of if I do it and I spend this money and I don't get it. Okay. Then you pull this out. It's holstered. It's not on your website. This is not, listen, this is, this is where I call the look around. When you pitch this, when your clinician pitches this, they do this.

54:35 Listen, I'm not supposed to do this, but I'm pretty confident. Don't say pretty. I'm confident we can do this. Here's what it looks like. What I don't like is pain-free because you can't see or that is a symptom, not a sign. I would go with signs. Can you show me that you've done this? Because they're going to go, yeah, I'm not a hundred percent. I'm So just be specific along the way. If then, now act like a lawyer. So what we're saying is, listen, if you do all these things and it doesn't happen, then my plan failed. But are you the part that failed? Did you not do it? Then how is that my fault? This is where when I first heard of value-based care, I was like, dude, that sounds like a huge risk.

55:19 Like, We signed on, but you didn't do it and I lost money, but I did my thing. This is where I will never do affiliate deals for podcast sponsors. So I definitely talked about your product for a hundred days and you might pay me for some of that. I definitely build a show every day and you might pay me. My job is to get them to know about your product, not to make them buy it. That's a human thing. Your job is to give them the plan. Their job is to do it. So I like this. I think you're ninety eight percent of the way there. I actually think you need less. I don't think you need to add to that. I usually like put the put the specifics. Yeah.

56:01 Yeah. All of health. Ben is saying all of health care should be like this. You can't put a cap on the time duration if going to the out. This is what we need you in the room, Ben, because I'm reading. I thought he just said six months, but then he said you can't put a cap on time. Give like a rate. Oh, I think what he's saying. I'm channeling Ben. Like, hey, listen, then I'll give you the money back or you can continue. Is your goal still to get to Orange Theory? Yeah. All right. Then we'll continue to work together until you get there. Maybe we're just eighty five percent of the way there. So let's work together. I'll continue to work together with you. I'll give you the money back. Now we walk away or we continue to work together for six months to get you there at no additional cost.

56:45 Yeah, this is what I was going to say. This is a risk contract. You agree to the KPI that are realistic to show you have done your part. But in case the patient hasn't done theirs, there needs to be a way to track it. It doesn't need to be like a thing that you do in the courtroom. And here's my comment. They'd have to – I don't know. It could be like they have to video record them doing their HEP. Yeah, I don't know. Like three days a week or something, which would cause more – It would be more work for the patient. But if you could document those videos and then you look back when they go and you're like, well, you only did four minutes each time. This is where I don't like it with Tony, which is not for everybody. And now you guys are like splitting hairs and you're arguing with the person you're supposed to be helping.

57:25 This is where I don't like it. But I will say lawyers do do this. lawyers do take on cases like in disability claims and they say i will work for you for free if we win because they know the case is huge though that's the difference yeah and if i win i get thirty percent and you're like thirty percent that'll be hundreds of you and you're like or you could just pay me along the way which do you want that's where i don't like this on your website but i would like it if you're like first you gotta decide who is this right for And then do that. Do it as a test. But first, the hard part is defining who it's right for, who it's not. I think it's more important to decide who it's not for. And then what does it look like?

58:06 That's realistic. Videotaping my workouts, I would never do that. I would just be like, okay, this is like if you don't like the food, but you ate eighty percent of it and you sent it back. It's like, I looked like you like it, chief. Like, I don't know. You didn't like it. You ate most of it. What do you want me to do with it? I made the food. You looked at the menu, you ordered it. I like this idea. This is a psychological thing. I think the amount of people that will actually push back on you or ever ask for their money back is terribly low. Right. It would help with conversions on the front end, which is, that's the whole point. I don't know. I think the advantage to being a small business like this is we don't need large volumes.

58:48 I don't disagree either. I feel like this is a hard road to try and convert a couple of potential clients that with sales and all the other stuff you understand, you could do it a different way. How many do you think you have? Let's say you have a hundred patients. How many would you need to give this to push them over the edge to jump in and go with you? Is this the exception or the rule? It's not the rule because you wouldn't be in business if this was the rule. Well, no. So because right now we're predominantly visit by visit. Now, I have sold some packages. Oh, I see what you mean. have sold some you know we've done some packages but this would be like here's the thing like this also this whole idea came from alex ramosi because he was doing this type of a style for brick and mortar businesses and gyms and all that and what what it does in terms of helping the whole flywheel of the business is if you're selling this amount of money up front one thousand three thousand four thousand whatever dollars up front per person Understood.

59:49 That's like, that's the return on ad spend, the ROAS, like when you're paying for Facebook ads and Google ads and Instagram ads, you know, meet meta ads. So you get that money and you're using the profit of that new customer and you're getting more new patients and you know, each month and you're, and you're using the cash of those packages to pay for the ad spend and to get more patients and customers. I don't think, I don't think you would lose doing this. I don't know if you need to do... Yeah, I would do this. I would try it. All right, we're almost at time. We got to do parting shots. But before we do, I want to make sure we don't lose money here. Our sponsor, what do you guys think this is? What do you think they sell?

1:00:30 Up next is progress notes. If it exists, it probably happened. You can do things better. Write it in paper and pen or like the old Ten Commandments. You could chisel it as well, but progress notes, just write it and do it better. Yes. Progress, close. It's a regular notebook that somehow counts as documentation. You write whatever you want, whatever you remember. In handwriting, no one can read. Now it comes with coffee stains for authenticity and random page that just says better. Yeah, I got to dig into the details better. Progress notes. If it exists, it probably happened.

1:01:12 This just backs you up. This is a record of nothing. That's what progress notes is. All right, parting shots. Parting shots. Implantable, not wearable. That's the future of PT. Tony wants to be inside you. Keep going. Dave, parting shot. How do I follow that? Quickly. It's not. It's not. Implantables will not be the future of physical therapy. What's your parting shot then? My parting shot is the future will continue to be this bifurcation, this split of the low cost, extremely thin margin of physical therapy practices or out of network self-pay that have higher margins. And yes, there's more of the sales hurdle, which we're just talking about.

1:01:55 But those are the two options moving forward. My parting shot will piggyback on both of yours. The future will be better for the people who pay attention. I think the people who are paying attention. None of what we just said is going to come true on this show. Some of it kind of will. And we're all going to be Nostradamus because we're geniuses when we look in reverse. We're back on Tuesday. Have a good weekend. Tony Maritano on YouTube at Total Therapy Solution. Find Dave Kittle at conciergepainrelief.com and on YouTube at The Dave Kittle Show. And follow Jimmy McKay at PT Podcast on YouTube, the socials, and wherever you binge podcasts you pretend are for CEUs.

1:02:40 And hey, just a reminder, none of this was for advice. This was for entertainment only. Our lawyers say that counts. Thanks, Keith.