Why PT Clinics Feel Broken: Hiring, Efficiency and the Race to the Bottom

0:02 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, Dave Kittle. Jimmy McKay, good morning. How are things in the Big Apple today? Things are great. We got the first week. My new full-time physical therapist, Dr. Crystal, she's on her fourth day today. She's getting momentum, already seeing multiple patients per day. So things are great. Onboarding is going smoothly. And something that you obviously will like and Jimmy will like, which is we're already recording content with her.

0:47 I think I saw one with her, right? Yeah. I didn't even post it. I didn't even post any content of her yet in the clinic, but we have clinic content. We have sidewalk, uh, public content with her. Uh, she's already very, very comfortable in front of video. And, uh, obviously we'll continue that trend. And, uh, we might even use some of these video assets to do some meta, you know, Facebook and Google or Facebook and Instagram ads, but we'll see. So the question every clinic owner is going to ask you is how'd you find her? How'd you find her? What'd you use? Everybody wants a different Kung Fu. I was talking with some practice owners yesterday and they were just like, Oh, this plat indeed sucks or this sucks or that one sucks. Everything sucks.

1:28 And then they change and they get good again for a little while. So how'd you find her? Was it organic? Was it, was it, was it a service? What was it? Most of the time it's LinkedIn, but this was through Sturdy McKee's PT Match. And if you're not familiar with it, I should get something, but I don't get anything from Sturdy if I mention it. But it's like a referral fee paid out on the sixth day. So they screen the candidates, they get the resume, they connect the candidate to you over email, and then you do your thing, you schedule your call, all that. So then it's on you to actually take someone through a process and qualify them or disqualify them.

2:10 And then they get to work with you full time for sixty days and then you can cut bait if they're not the right fit or you would pay the referral fee around the sixtieth day if you believe that you're going to. want and keep this full-time physical therapist clinician how to sturdy find the pts because that's the hard part right it's like becoming indeed right getting the roster how does he do that i interviewed him about it i can't remember Yeah, I mean, I think they have done either some organic listings. Also, by the way, I also have to pay Sturdy a separate fee. I have to pay PT Match a separate fee, and they will post ads on Indeed or elsewhere where it's kind of like anonymous, if that makes sense.

2:54 Like the candidates are like, oh, that sounds interesting, and then they reach out, and he's the one posting it, if that makes sense. So it doesn't say concierge pain relief. It says, you know, like the – hybrid home visit but not home health outpatient you know four to six patients a day travel around the city that type of thing so he they kind of draft and write up their own ads on i think link maybe linkedin indeed elsewhere uh also i don't know how but he's done stuff to like make an email list so um this therapist actually had interviewed elsewhere two years ago in the city she had a couple different jobs in new york city and then I guess either she reached out to Sturdy or he's sending out an email newsletter kind of thing.

3:40 And maybe it was on there. I don't know exactly how it got her attention. But I joke with Sturdy all the time. I'm like, I need to figure out how I can get in front of these people before you so I don't have to pay you the VIG. But it's worth it, right? If this person sticks around for a year, it's well worth it. Of course, we'd like it for it to be zero, but it's still worth it because... my question to you guys was going to be, and this is going to vary on everybody. What, what is the big four? You know, somebody told me in PT school, right? When we're learning about pathology, there's always going to be a leading cause of death, right? You solve this one and the next one pops up and they're going to change. What are the big three or four?

4:20 Hiring's got to be number one right now for practice owners. And we'll stick with outpatient, you know, practice owners. What are the big three or big four behind hiring? Big three or big four what? Biggest problems. Oh, okay. Behind hiring specifically. Yeah, if hiring's one, what are the next two? What do you think, Tony? I mean, I got a couple in my mind, but what do you got? Oh, go ahead. I don't know. I got to think about it. Okay, so hiring would be on the clinician service side, right? After that, it's got to be, obviously it depends, right? So Tony is in network, right? So he sees a lot more patients and it's like a lower revenue per patient per visit.

5:12 compared to us, so we see less people, but we have more revenue per visit. So it depends on, even our two practices are very different, right? Tony's not looking to really expand the team, but if he were, he and I would commiserate on the same challenges of like the recruiting and the hiring. So that's definitely, it definitely continues to seem like it's number one across the country. And then after that, it would be either still getting in front of more new patients. Now, Tony doesn't really have to do paid ads because he's been in the community for so long and people know him and a lot of his previous people kind of reactivate or the spouses tell the other spouse or the neighbor or the friend or all that.

5:53 But for us to get a new therapist busy right away, we're cranking Google Ads right now. And I'm looking to either outsource the meta ads or even possibly learn it and do it in-house. So we'll see if Claude or ChachiBT or whatever can dumb it down for me. And maybe I'll test it and do it. So I still think number two would be getting more leads, like more new potential patients in front of you with the caveat that some practices like Tony don't need that. And he will not say that that's number two, maybe. And then at least for us, number three would be then like retention. So like lifetime value of the client. Again, assuming that we're delivering value and they love it and they value it and they see results and it doesn't matter if it's home visit or office visit.

6:41 But if you're doing paid marketing, like we are, not only do we want to recoup money that we're spending on ads, but we also want the people that we found through those paid channels to not just spend three hundred fifty bucks or spend a thousand bucks. Again, assuming that we're delivering value, we would want someone to stay with us for months or years, and that would be thousands or tens of thousands of dollars in terms of lifetime value. So those are like my top two or three. What do you think, Tony? Anything resonate with you? yeah i think you know we face the same challenges like for us it's do i have a budget to afford what the person's going to want to get paid do i do i have a financial budget do i have an emotional budget like do i want to invest in building the relationship and getting to know this person and understanding what it is they they really want why did this therapist come to dave why not go to a million other choices you know she had Do I want to build that relationship?

7:46 I was just on the phone last night, quick story. One of my favorite employees, she was a physical therapist assistant, amazing person. Like, I had a video of my now-thirteen-year-old when he was, like, five years old, walking on her back, giving her a massage in the clinic. And, you know, it was hilarious. So, like, I reached back out to her and I said, hey, look at this video I found. It's hilarious. You'll get a kick out of it. She's not working anymore. She's mom to three. And, like, those are the emotional relationships at this size of business that you're dealing with.

8:27 And I think a lot of employers at this size of business might not want to get emotionally invested and have to do that. When we were at five locations, I had zero emotional investment. You were a financial investment, not an emotional investment. Somebody hired you for me. Somebody fired you for me. Somebody paid your payroll for me. I might not have ever even spoken to you at that level. But here, one location, one, you know, small team, totally different. So those are some of the things that I think are the barriers we're dealing with as an owner operator, small provider.

9:07 Yeah. Makes sense. I'm going to bring up an example of something I created for someone just yesterday. And the idea was people are all having the same problem. And you know how I come at things. I come at things almost knowing nothing, which is almost my superpower. My superpower is lack of knowledge. And I remember just asking these people, like, well, why don't you do that? And they're like, well, no one else is doing that. I was like, ding, ding, ding, ding, ding. No one else is doing that. Why aren't you doing that? So I've got an example. I'm just uploading it right now of a different way. So the methodology was talking to someone and what are people consuming more than anything?

9:48 Short form video, right? Do PTs have to flood Indeed to go look for a job? No. They got jobs falling off the streets like coconuts, right? So you need to be in front of them where they are. And then the other part is... Listen, filling a job in like a dope place like Austin or Phoenix right now, for some reason, there's more PTs in Phoenix. Like you could walk down the street and bump into six PTs because they picked where they wanted to live. The problem now is you can't fill the jobs anywhere else. So I said, be funny and make a short form video. Probably not take this physical therapy job.

10:31 If your main goal is to tell people that you live in San Francisco, Modesto, California probably isn't gonna scratch that itch. If you need Lake Tahoe out your front door, also no. But if you wanna start around a hundred grand, get twenty thousand dollars toward a sign-on bonus or tuition assistance, lives somewhere that costs considerably less than the bay area and works somewhere that pt students have literally gone from clinical rotation to clinic director the modesto starts looking a little different golden bear physical therapy is idea is what i sort of just sat there i was like ryan reynolds makes mint mobile look like a good idea like what when in what planet is mint mobile a good idea although the question is what's the difference between mint mobile and at&t like i don't know it feels crappier but for fifty percent left would you consider for ten dollars a month would you consider it and ryan reynolds had this great idea where it's like instead of getting paid like you know seven hundred fifty thousand dollars to do a commercial He's like, I'll give you three million dollars and own part of the company and then I'll do a budget.

11:43 He took the Shaquille O'Neal route. He's like, yeah, listen, but by the way, yeah, you should be asking for equity from practice owners across the country. Right. Well, there's two things. Right. Number one, anybody could do the video that I just did. No, not like you, though, but not like me. Right. And they could. They just haven't. Why? Reasons, right? I could go, you know, I could learn how to, you know, fix my roof. Why am I not? Don't want to. That's not my business. So there's two things. One, you should be creating videos like that or let me do it for you. And then two, it's the distribution. You still run into a distribution problem.

12:23 You've got the funniest video. Although my angle with this was the funny will make it spread. Because I think most people, now I'm getting in the heads of people because my day job is ninety percent this. I need to get like five hundred people to reply to this. No, you don't. You need to get one right person, one right. I want to piss everybody off. I don't want to do and I don't want to do a phone call unless it's the right person. I think we're I think we're quite literally some people are looking at it from the wrong direction. So that was my I was like, don't sell the job. A hundred and five thousand dollars is not mind-blowing.

13:04 But when you start framing it different ways... It becomes different. I mean, I'll tell you where I got this story. I was at Mardi Gras once, and I was hanging. It was met a group of young women. And I saw the smallest, shortest girl outthink all of the girls. Now, I don't know if you've been to Mardi Gras, Dave or Tony, but there is an exchange of beads for something. And this girl was the smallest girl. And now she's yelling up at a balcony and the larger the beads, like, you know, you can sort of bargain your barter. It's a barter system in Mardi Gras.

13:45 And she was smart. Instead of talking about size, she talked about color. She said, these are the pinkest you're ever going to see. And I remember looking, I'm walking by in the street and I go, what does that even mean? That's the point. Different. It's a purple cow. What does that even mean? Right. Now you got to see it. Now the guys were going insane. They're like, everybody's visual. And she switched it to color. And I remember thinking, this girl's a genius. I'm like, what do you do for a living? Ad executive? She's like, no, I'm a nurse. I'm like, but you thought about it. So that's the idea. If you're not going to outspend someone, don't make the ad about how much money.

14:27 Mention it because you're going to be wondering. Don't leave them wondering anything. if you only need to find one person in Modesto, right? Or one person who goes, I'd take, I'd go anywhere for twenty grand, a twenty thousand dollar sign on Bono. We could do anything for a year or two. Sure. Or I got an aunt there. You only have to find one. And I think we're we're all rushing to Indeed to outspend each other on Indeed for people who don't qualify. And I think that's I don't know. That's the other that's the other direction that I was looking at. So I made a series of those, fired them back to the company and they were like, oh, Yeah, I'm like, these are nothing like you've ever done before. Trust me on that one.

15:07 But now you've got to get the right person who's bold enough to go, yeah, we'll run these. We'll put a hundred bucks behind each of these and see which one plays. That's my strategy. not not sure if that you know tony got busy with something or he was purposely getting away from the camera when you started talking about mardi gras and beads and all that but he's back and uh the one now we're not doing mardi gras and beads or even a lot of you know jimmy mckay style of that type of video but i don't know if you guys have caught this recently we're starting to do some food reviews and I'm calling them, I'm calling them our no cred food reviews. And I said, you know, everyone does food reviews online. Everyone thinks they're like the smartest. And, uh, and I'm not, and I'm, I'm not saying you should even listen to my food reviews.

15:50 And I'm just the first one to say it. I'm just the first one to admit it. Um, and that's, that's one new thing of, uh, the top of funnel to just, and this, this is instead of doing a Tik TOK dance, this, this is what we're doing. We're going to, we're going to mix in some food and drink reviews. It goes to this, right? It is. Everybody thinks it's attention to action. It's not. So you doing food reviews, even if I I've told people before with email marketing. Even if they never open your email, I shouldn't say never, even if they rarely, one out of a hundred open your email, they haven't unsubscribed and they've seen your name in their inbox, ninety nine times. And if you don't think that's worth something, drive along a busy road and look at billboards because companies know it is worth it and they spend just to be seen.

16:38 It reminded me of the Barstool Sports. Who's the guy who does the pizza reviews? Dave Portnoy. Yeah. Like, why is he doing pizza reviews? That's the most weird. Because it's his thing. And he's like, this is my thing. And I'm going to do a thing. And it doesn't make sense. It's a little left. No, no. Not sports. There is a little connection, right? Because his favorite, when he does the pizza reviews, his favorite type of pizza is bar pizza and barstool and go to a bar and watch sports on the TV at a bar and you're yelling at your team and all that. I think maybe it's not that obvious. I think it's obvious, but maybe that's their connection. For us, the only connection is we're going to just different restaurants in New York City nearby.

17:21 Right, geographically. And I'm definitely like we're never going to flame any of these restaurants. Right. Because, again, it's like a fellow business owner. So I'm never going to say anything like really bad. But the idea is like we're nearby and like that'll maybe assist in some affinity or whatever. People people reckon. Oh, yeah, that's what I at least know. Are you let me ask you this on Instagram with every one of these posts that you're doing. Are you putting your location? If the restaurant is has a location on Instagram, yes. I feel like every post you do anywhere in New York, you should put like your location. So it starts to get seen in the, in that area. You know what I mean? Yep. Like when I go to a conference and a couple of days later, I'm releasing videos.

18:02 I release. i put the address of where i shot it so that like the because you know if i go to apt virginia or whatever i want virginia people to see that because like i was here here i was i was with you guys my audience will still see it but my non-followers the idea is in that geographic area i want your attention i think it's great the reason dave portnoy does you know pizza reviews is because his audience likes pizza or like, you know, it's a dude, right? So like, it doesn't make sense if you're like, well, you're about sports. Everything's shit about sports. It's less than one standard deviation away. I mean, who eats, who watches sports ten times and doesn't like eat food, right?

18:45 It's like, it goes hand, quite literally, hand in hand, right? You're gonna drink something, you're gonna eat something. So it makes complete sense. But like, if we wanna go down the rabbit hole of Barstool, have you seen what they've been doing on the side? They're now almost a reality show. They created a cast of characters, a Marvel Cinematic Universe, right? This guy does the baseball stuff. These guys do the football show. These guys do the college football show. These guys do the SEC college football show. And they talk about it every week, short-form video. Now they bring those characters together, and they're doing, like, one day like wiffle ball tournaments, videoing the crap out of it from thirty angles, finding the funny, you know, these guys aren't, you know, getting drafted, so it's usually funny, awkward moments, and then they build it around that.

19:35 Does that make sense? Yeah, because now I feel like I know this character. And this guy made a diving wiffle ball catch, but crashed into the Gatorade container and it went everywhere. Ha ha ha. I know this guy. So Dave doing food reviews is to me just like that. It's one standard deviation away from him talking about knees. And now I know this guy. I like this guy. I trust this guy. I take action. That's what I see. And I don't know if you've seen this. Apparently, it's like a new TikTok trend, but there are random accounts now following strangers on a sidewalk, videoing the stranger and analyzing their walking, their gait. And these are non-physical therapists.

20:16 And you guys all know, I'm sure you would agree, I believe, that there is no better person on earth than a physical therapist to evaluate someone's walking and gait pattern. So there's a couple of accounts on Instagram. And then someone told me, so I was in the clinic yesterday. One of Dr. Ethan's patients is like a teenager, like maybe eighteen, nineteen. And he's like, oh, yeah, it's like a tick tock trend. I was like, oh, wow. Because physical therapists are the best to like imagine in New York City, we're walking on a busy sidewalk and you're following somebody. Now, of course, you're you're holding you're holding the lapel mic like this. Right. So like they can't even really hear you if they're right in front of you. So I would be like, I haven't done this yet, but I'm going to do this like probably today.

20:59 So I'm going to be like, watch, you know, walking behind somebody and analyzing their, their gate or how they're walking and maybe make fun of some tourists, which every New Yorker loves and can agree with. Because tourists will kind of like mosey around and like look up and take pictures and get like, get in the way. So it's like, boom, there's another piece of content that like, that that's totally unique. That's a little bit more fitting to physical therapist compared to an account. That's just like a random account. Let me yes and that. So I say once this trend has already started, right, let's trend the trend. Let's start an Instagram account called Gate in the Wild.

21:41 Gate happens. right where we find that's already that's already like a branded thing from so is it that's fine that's good but we will find all these videos and do it what they all do which is they rip videos from other people and repost them we can do like mystery science theater three thousand we can analyze their analyzation so we can take someone's video and go he's wrong so what this actually is is and we can analyze their analysis yes we're all photographs of foot we're all photocopies of photocopies of this point there is no way anyone watching or listening is gonna get the reference of mystery science theater i love that yes yes that's a great one memories that come back i must be right on the cusp of that They were talking, yeah, I was definitely, I think I was on the cusp of that too, where I was like, this is cool, I think, right?

22:34 And then you watch it enough and you're like, I'm in. Okay, I got it. These guys are just like, that was the first like, I don't, it felt user generated. I mean, it was low quality sort of on purpose, like to give it sort of like some schtick and gravitas. I think I heard a thing where they were thinking about redoing that, which would have been classic. There are so many things that they could come back with that, like, you guys were probably on the cusp of, I was in the meat of. Well, they did, right? They redid A-Team. They've poorly redone G.I. Joe, like, twice. I wish they'd just stopped. I mean, Transformers was a monster. They redid He-Man.

23:17 I, they, they at least went at it with tongue in cheek. So they didn't miss. It was tongue in cheek, but yeah, it's, it's, it's, it's, I know you guys love my pyramid, but it's nostalgia is high up on the pyramid, right? It's way, way up. Well, it's the middle of pyramid, but I think it brings it. I think it brings up a good point. All right. So Scott is saying instead of reality TV, reality PT, uh, know tony feel free to say you've been talking about this that yeah for a while that you could you know that at some point you can replace the income with the content that you shoot you'll just need more people in the doors you could provide pt at some point for free uh in exchange for the ability to use it as video and multi-purpose Yeah, I think we should have the reality, you know, follow this patient from the entire journey from evaluation to discharge.

24:10 We should do a, oh man, I just had it in my, a survivor style series. You get kicked out of the physical therapy clinic if you don't, you know, we do competitions, we create teams and alliances and all the secret stuff. We could, I mean, you Mr. Beastify, the physical therapy experience to make it something you take it to fear factor you you bring in that kind of stuff like and there are plenty of things within the profession already i go back to you guys are desensitized to it but who the heck sees a seven inch monofilament needle that you're gonna stick into somebody's muscle right and poke it around and spin it and tweak it Tony, I know you saw the episode with Sean Pastouche.

25:04 Eighty percent of his content is him on the Jersey Shore boardwalk with an A-frame, literally handwritten, asked me about health, asked me about fitness, and then he just lapel mics it up and has convos all day. And someone was like, oh, look, I don't know. Tony's getting dollar dollar bills. Cash, real cash. Cash money. For all the young kids watching, that is what cash money looks like. Can you Venmo me that? How do you Venmo me that? D three is a good idea. Which made me think of Sean Patush. What if you offer free gate assessments on the street? Your gate sucks. Changed my mind with the free gate assessment. I mean, this in Central Park for Columbus Circle, like an iconic place, Times Square.

25:50 So this is the thing. When Dave first introduced that minutes ago, I was not aware of it. My immediate gut response is, ooh, that can be tricky because that could be perceived as you're taking advantage of people, you're making people look dumb. That can go in a negative direction really fast. But there are so many already media guys out there I could see a deal where you start the video, you see a gate, you run up to the person, and you're like, hey, would you be interested in, you know, and talking about this, or this is what I noticed, or hey, I'm Dave Kittle, licensed physical therapist, and I want to, you know, do this, or involve the person.

26:33 There's the one where, like, they roll the basketball to a pedestrian, and then they try to shoot a basket, or they kick a soccer ball in the middle of the street. Great concentration of attention. Getting that person involved, I think, completely changes the dynamic and be like, oh, yeah, I had no idea. It's the Judge Judy angle, which is we'll settle your case and pay the judgment. You just let us film your court case. That was the whole idea. None of those people paid any of those judgments as long as we can use your information. All right, Tony, you shared something in the group chat. Looks like a big string of text. Let me bring it on the screen. Yeah, pull it up.

27:14 And basically for, again, for people kind of watching, listening, this is the dry segment. This is the boring stuff, but this is from the CMS, like final rule proposal, I think for two thousand twenty seven. It's specifically talking about RTM services. So therapy practices had been billing RTM for a long time. Medicare effectively comes out and says, hey, we didn't realize RTM is going to be less expensive than we thought it was. Our original projections were that the equipment for RTM was more expensive. It's less than we expected. And what they're effectively saying is we want to consider lowering reimbursement because it doesn't cost as much.

27:55 Yeah, that's a better one. So it says, we also are proposing updates. That means reductions to how the services are valued under the payment model. We understand the devices may be available at a reduced cost compared to our initial estimates. Go ahead. So the RTM company is out there. We all know a few of them. So are they contributing to even more payment reimbursement reductions? jimmy i don't i don't think they're contributing to it i think it's um how are they how are they not based on what you just said tony all right yeah walk me through this so rtm wasn't a thing it became a thing you're only going to get paid what a cup what what you know medicare says you're going to pay and everybody follows medicare but what and then so why is it why is it being reduced if they found that it's effective It's effective, but it doesn't cost as much as they expected.

28:55 So the big picture. It doesn't cost as much to provide? When you look at the way Medicare establishes its rates, it's not just a simple, we're going to randomly pay you twenty seven dollars for a unit of nine seven one one zero. It's where are you located? So there's a geographical component. What are the established expenses that go into providing the service? What are the liabilities? What are the personal injury insurance? All of these factors come into play when they're establishing the fee schedule. When one of those factors changes dramatically, now theoretically, we're paying therapists more, the reimbursement should go up because that's a factor in calculating reimbursement.

29:40 It hasn't happened that way. Conversely, when costs go down, they can reduce rates. Medicare is saying, Dave, if you're going to bill us, we're only going to allow this much profit. I mean, it's basic price fixing at its best. Like there's no, it's price controls, it's rent controls, it's all that kind of stuff. This is where the government is, but they're paying billions of claims, you know, so this is what they have to do. Plus they don't have the money. They need to reduce costs. So yes, potentially inadvertently. The RTM companies are trying to save clinicians money and improve clinicians' profit margins, so they reduce the cost. But what happens is the payer says, oh, I'm going to take that money.

30:24 You're not going to get that money as a profit. That's what they're proposing. Yeah. What I'm putting here, though, is don't look at this at face value. Let's go three levels deep. What is this really telling us about the philosophy, the mindset, the motivations behind CMS? CMS isn't looking for you to make more money. CMS isn't looking for the efficiencies to go to the provider. They're looking for the efficiencies to help them balance their budget. And when we see therapists battling for higher reimbursement, it's falling on deaf ears because nobody is going to pay you more for the stuff you're doing. I think we can extrapolate that out and we can say, well, wait a minute, if RTM platforms are becoming less expensive, Medicare sees that they're gonna lower reimbursement for the service, what happens when Hinge Health, Sword Health shows Medicare, hey, we can treat thousands of patients for a fraction of the cost that Dave and Jimmy and Tony- It goes even lower.

31:28 Yeah, like absolutely. Again, inadvertently, potentially, But that gives them justification. And then you go the third level deep. We look at the clinical research. Clinical research says, hey, total knee replacement outcomes over a population are just as good with an unsupervised home exercise program as they are if you sent every one of those people to physical therapy. And so now we have clinical justification, documented peer-reviewed journal articles that are showing you don't need twelve, fifteen, twenty-four physical therapy visits one-on-one with a physical therapist.

32:11 Most of you will do fine with a couple pictures and sent home. It's called Jevons Paradox. It's when something becomes more efficient to use, we don't use less of it, we use more of it. Like coal. We found out how to make coal efficient. So we didn't use less coal. We're like, oh, it's more efficient, so we'll just use it here. We started using it everywhere, right? Trains and buildings and heating our homes. It was like, let's use more of it. But if you sell coal, you have to sell more to make the same amount of money. Now we're coal because we're more efficient or the thing that we provide, but you can provide in several different ways, is more efficient. The price per nugget of coal or per unit of physical therapy would go down, I guess it sounds like.

32:51 And so, in other words, owners could continue to get squeezed implementing and using this whole RTM service, which I respect anyone that's in the game, but I don't want anything to do with RTM. And this is another reason why this whole thing is a race to the bottom. It doesn't matter if it's outpatient or in-home PT visits, whatever unit you're talking about, whatever billable units or the whole RTM thing. Medicare and then obviously the adjacent connection of like the commercial payers that then kind of model a lot of their future payment off of Medicare and CMS. You got someone else setting your your fee schedule. So yeah, don't complain when they pull the rug out and they continue to squeeze you.

33:34 Yeah. so this this is where we see the the alignment of incentives kind of go opposite directions you know like now so the practice owners are going to be like well i don't want to be more efficient because the more efficient i am the less the less my reimbursement is software companies are like we can't charge less because if we charge less the payer will pay less like it doesn't help the provider for us to provide you efficiencies and you see that in government departments everywhere my budget you know is set if i don't use my budget i lose my budget so i need to spend more money i need to throw money out the door the first time i ran a radio station there was another guy who ran a different radio station same building same company he sort of took me under his wing it was like This is how we do budget.

34:24 The first year, he sort of walked me through each process and didn't just show me what to do. He gave me the reasoning behind it, which is, that's the gold, right? It's not just tell me what to do once, then I need you forever. And he taught me that. I was like, no, look at this. I'm going to make the GM super happy. Because I didn't spend all the money. And he looks at me, he goes, my man, spend the money. I'm like, but why? And he goes, because they're going to say, then if you save thirty percent, then you need less thirty percent less next year. My incentive was not the same because he's like, you might need thirty percent more next year to get the same bang for the same for the same buck. But you don't know. And if you don't got it, you can't do it. And I remember just sitting there in my chair thinking this can't be right.

35:05 It was right. If you put Scott's comment back up there, same thing, you know, logically pay the people more that save you the most money. Absolutely. This isn't a logical system, you know, and even in the past when I've researched topics like this, not just Medicare, but other commercial payers, there are rules in place. that the insurance company has to pay a portion out of the profits they can keep. The higher they pay out, the higher the profit they can keep. But it's not worth bothering for a twenty seven dollar unit of therapy, right? I want to pay for more hearts and more lungs and more joint replacements and more big ticket items.

35:49 Don't waste my time with a bunch of little ticky tacky therapy visits. Tony, a minute ago, let's just show you how you can just have an idea, make an idea where we are in the world. You mentioned nine, seven, one, one, oh, earlier. You just said the code, right? And to you, you can rattle that code off. I hear that code. And we were talking about nostalgia and He-Man and Mystery Science Theater three thousand. I brought back my Etsy shop just a couple of weeks ago. And instantly I just I was like, well, we need like we need a Beverly Hills nine or two. I know mock up. of physical therapies, nine, seven, one, one, oh. And you can just generate that with just a couple of words and a prompt. And I was like, yeah, that is very similar to that TV show that we all watched growing up.

36:32 Dave, what's your zip code, where your clinic is? One, zero, zero, one, nine. So we need gate one, zero, one, whatever. No, see, I think zip codes in New York City are not... what they are in Beverly Hills, you would do two, one, two. That's the number of like, where, like back in the day where you were from, it's like, where are you? Two, one, two or seven, one, eight. Like, what are you? Or, you know, like, where are you? Nine one, four, like, oh man, you might as well be in Canada. Like in New York, it's more, it was more area codes like for phones. I think his, his gate segment would be gate two, one, two. Yes. Yes, that's it. Wouldn't it be better to say walk or walking instead of gate?

37:15 Yes, I believe that more consumers know what gate means, but I also feel like it makes it seem more sophisticated than it is. And that's sort of what you want. A little bit of sophistication. That's for my clientele. Yes, you're right. Central Park gate, gate. I still think you should do it like in iconic locations. You know what I mean? So people instantly know this is somewhere cool. Like, you know, on the lawn, the great lawn at Central Park or next to a statue. New York's got a load of statues you could. What about if they're iconic, like G-A-T-E, gate. If you're doing gate through the gate. in central park or gate you know something play on words like that before i get too far away so back real quick to that twenty twenty seven proposal the other big barrier coming down the line for uh rtm There were companies that came on the market and said, hey, don't bother your physical therapist with this.

38:12 We'll handle it. Contract with us. We'll provide the software. We'll provide the support. Our people will do the monitoring and your people can bill for it. and then you just pay us a portion of the reimbursement. Another proposal is Medicare does not want to see that. They want your therapist doing the monitoring if your therapists are billing for it. So these are W- two, you can't go to ten ninety nine anymore. Right. Oh, you know what? And now Scott's got me thinking. He said Walking Two One Two is a much better name. The iconic Dustin Hoffman clip from I don't even know what movie it's from where he's walking across the street.

38:52 The story behind it is they were shooting a scene in New York, but they didn't actually block off the street properly. So a cab almost ran over Robert Redford and Dustin Hoffman, and he slams his hands down on the hood. Hey, I'm walking here. And they kept it in the movie. Right. They kept it. The movie was a real take. I'm walking here. Might be worth because it's I mean, it drips New York. Right. He even says it in the accent in the in the New York City accent. That could be your intro. Like if you were doing it in radio, that would be the drop I would put at the beginning of everything. I would just program it once, push a button, start it, and then the video would play. Now we're getting to it. I need to figure out the whole Judy with the pancakes. I need to figure out how her editor, because I looked on her account, they only have like three hundred something posts.

39:38 So like every post is like an edited post of like another viral hook in the beginning. And then it's then it segues to Judy. I mean, that's the Instagram is showing you because they allow a remix feature unless you turn off the ability for your video to be remixed. It behooves you to let it be remixed because now a part of your video is going to a different audience. So that's their strategy. That's Judy's strategy is take a thing that's getting popular, steal it, and figure out how to twist it for pancakes. I don't think they're using that feature, though. Do you think they're just dropping the video? It looks like a totally different – it's edited way better than just the remix.

40:21 They use a video ripper, which is a program that can take the URL, figure the video out. I did one yesterday to show someone an example. Somebody – I won't say who – put up a video. They asked me for input. I gave it. I told them what their team would – I said, your team will do this. I think you should do this and this or this. They put out the video yesterday. They did the thing I said. I'm like, your team will do a C-minus job. They will do the thing. They will do mayonnaise flavored ice cream. And then I use the screen recorder because I didn't care about like high quality. I just want to show an example. I use the on-camera screen recorder. and then edited it in my app and then gave it to a friend and go, which one's better? And she's like, well, that one looks boring.

41:03 I was like, yeah. And I bet you if you look at the retention graph of that video, it's a cliff because the first three seconds are garbage. The first ten seconds were garbage. I'm like, that's a mess. But yeah, Judy's got the Judy's Judy and Judy's Judy's Cafe. If you don't know, just go on Instagram, look for Judy. She's this pancake house owner who has no business now being a tourist destination for people from miles around, making a detour to go have pancakes at her little pancake shop. It's brilliant. Because what do you think the cost of that is? It's a couple hours of that editor's time per week finding a formula and then, okay, tell me what to do, how to do it.

41:43 Someone needs to shoot it on site. Editor doesn't need to be there. The same person doesn't need to be good at both things. It's a brilliant strategy. Don't look. Guess how many Google reviews that Judy's Pancake House has on Google right now. I don't know. A thousand? No. For you to ask that question, it's going to be like a thousand. Yeah. Closer to a thousand. One thousand three hundred and sixty-three Google reviews. For a pancake shop in where? Where is it? In like... galesburg illinois which i don't know respectfully sounds like anywhere there's gonna be a sign welcome to galesburg illinois home of judy's pancakes that's what's gonna be on the sign because she's quite literally putting them on the map people are going out of their way to be like it's like a bucky's it's like we gotta go and we're gonna meet judy look i'm with judy look at judy it's it's way closer to iowa than chicago that might tell you enough And she wears the same weird, ridiculous little glasses.

42:47 That's a visual hook. That is not an accident. That is completely on purpose. She stands out. Boom. Two-tenths of a second into a video, I'm like, I don't even know this lady. What did Judy do now? What is Judy doing now? What is this crazy thing that she's doing now? And everyone's laughing here, and we're loving this. And this is the... upside of doing stuff differently and but then consistently doing it differently right so you're we're talking i'm talking about her i looked up her google reviews we're talking about how many posts she has on instagram the follower count is insane i think it's like follower account five hundred thousand or seven hundred thousand followers pancake shop in whatever's middle middle of you know where illinois You're you're mentioning her sunglasses.

43:36 I'm thinking like every video starts as some random hook of another video and then it segues into her. And then she you know what she does in a lot of the videos. What is she like? What is like her part of the video? I'm Judith. Hey, I'm Judy. And I don't know what else. Come buy some pancakes. It's like a call to action. It's like a mini sales pitch call to action. Or it's like, buy my pancakes. It'll be like other products. I think they have the pancake mix. They have their own packaged goods. I don't know, but I'm going to guess they probably sell it on their website.

44:16 I think she's even smart enough to know there's a window here. This jumps the shark at some point. where people don't want to see this anymore, they engage less, I got to cash in on this as quickly as possible. Good for her. Good for her. Excited for Judy. All right, finish your thoughts on RTM. Scott, it looks like you left him hanging. Where did he say finish my thoughts about RTM? Finish your thoughts on RTM. He doesn't even know who Judy is. Me and Dave went on a Judy diatribe. Yeah, I think RTM is in line for some big changes. We don't know what the changes are going to be. These are the proposals. The proposals don't often work out the way they expect it.

44:57 Scott, I don't know if you're doing RTM. I know that we've tried multiple times. I love the RTM companies. I love the guys behind the companies. I just couldn't find a profitable way to do it, especially when I could just do one more visit in the month and pretty much make the same money. You know, for our style, our model, our treatment philosophy, RTM just, it wasn't something I could roll out effectively in my business. All right, we got about ten minutes left. Is there anything we didn't talk about? We started off with, like, the biggest problems in practice, moved to a little RTM, moved to a little Judy's Pancakes, which now I'm hungry. Now you're talking about pancakes. I'm a little hungry.

45:38 I'll just mention that I think RTM respectfully is the biggest waste of time to make. Tony and I sometimes disagree and we're on opposite sides. And sometimes we're like right in the middle. And I agree with them that like, what is it like, three hundred dollars per patient per month or so? I mean, you got to be doing volumes of patients. to even make it make any sense. So yeah, why not just see like another in-person, in-office visit, which kind of detracts from like the whole reason why they're like implementing the remote therapeutic monitoring. So again, it's just so ridiculous. Practice owners, I mean, do the math. Look at what... obviously you want it to be helping patients, but like some of these RTM providers are like, we're going to send your Medicare beneficiaries, these automated text messages.

46:23 And if they reply, yes, or I'm doing my home exercises, uh, that counts as like engagement. But then the actual Medicare beneficiary, there is no proof that they actually got off their butts, got off the couch, did a squat walk, did anything. It's just a complete joke. And I just like to put it out there where I stand. So if anyone's curious, that's my stance on it. I like the idea. And I think a lot of us do it naturally. We do it already. We have some version of it already. It's just not a billable event because it doesn't check all the boxes. But I text with my patients. I communicate with my patients.

47:05 Uh, is the juice worth the squeeze for everything? For some people, it might be a lot of people that might not be. Yeah. I wanted it to be, I tried to make it. I just couldn't get the system to, to work for me. All right. You guys want to do parting shots? I'm going to be exhausted talking about another. Judy, I already want pancakes right now. All right. Parting shot. I think once again, we see the power of social media. We see the power of connections, whether we're trying to attract new therapists, receptionists. patience like whatever it is you you need to put yourself out there and you need to let people see who you are i've never met scott in person but i like him because i like the way he thinks i like the questions he asks i like what you know his business philosophy from what i've seen that's what we need to put out on social media yep dave parting shot Uh, just, I'm just going to continue to focus on what I'm focusing on.

48:08 And I think anyone that's ever watching or listening, like, yeah, you can kind of test RTM. You can look what else is out there. You can try other things, but at the end of the day, like whatever is best for either your patient, your client, like your end user and customer and, or what's best for your team or you as a practice owner to continue the same business so that you can continue to make an impact in your community. Yeah. And for us, like, rtm is definitely not it um and i don't think it ever will be for a lot of practices but um for us yeah just continuing to focus on what we're doing with out of pocket and providing you know some amount of hopefully great value for some folks and we're not for everyone and the same thing with rtm like the rtm companies might watch this and be like yeah well we're not for everyone and you know dave obviously you're not the right fit yeah i'll spin off of dave's idea I think we're trying to out indeed everybody.

49:05 I'm just talking about hiring right now. And when everybody's doing the same thing, nobody's doing anything, right? Doing more of the same thing is not helping. So when you're stuck, ask what is no one doing? Well, that's a lot of things, right? But what are your targets doing that you're not? Where are they? What are they doing that you're not there and you're not doing? The cost to test this out is incredibly inexpensive, right? I mean, people are throwing around twenty, thirty thousand dollar sign on bonuses. What if you gave me a third of that and said, go experiment with a bunch of ideas? Go put one hundred dollars behind ten videos for a thousand bucks.

49:47 You don't need a thousand applicants for your job. You need one right one. That's it. We'll see you guys on Tuesday. Enjoy. Enjoy the long weekend. Go do not labor. Let me put this out there. So we pay a really expensive referral bonus for even PT match. And I tell my therapist, hey, there's a structure of when I'm going to pay it out, like the first sixty days, one hundred twenty days, whatever. But I'm going to say to Jimmy here publicly, Jimmy, seven thousand dollar sign on seven thousand dollar referral bonus to you, Jimmy, if you find us in the future, because again, we got we got other candidates in the pipeline, but I'm trying to choose the pipeline for the next six to twelve months. So, Jimmy, if you find us a physical therapist that stays with us for the sixty to one hundred twenty day probationary period, whatever, there's there's like steps, a couple of steps of how we're paying that out.

50:37 But I can send you that separately. But basically, if someone stayed with us for more than one hundred twenty days, then, Jimmy, we would be paying you full seven thousand dollars. You're putting a bounty. This is good. These are good bounty. It's like, find me good people. I pay good. I will pay people to find me good people. That's a good use of cash, in my opinion. So just lighting it on fire and handing it to indeed.com. It's just my personal. Exactly. Exactly. Do not labor this weekend. Not too much. We'll see you guys on Tuesday. That's it. We're out. Boys, what the hell are you doing? Follow Tony Maritano on YouTube at Total Therapy Solution. Find Dave Kittle at conciergepainrelief.com and on YouTube at The Dave Kittle Show.

51:18 And follow Jimmy McKay at PT Podcasts on YouTube, the socials, and wherever you binge podcasts you pretend are for CEUs. And hey, just a reminder, none of this was for advice. This was for entertainment only. Our lawyers say that counts. Thanks, Keith.