The State of Outpatient PT: 2025 Into 2026

Alliance Physical Therapy Partners: You’re listening to the PT Leadership Podcast where outpatient physical therapy leaders come to share their insights with your host, Richard Leaver.

Richard Leaver: Welcome back to the PT Leadership Podcast series. I am excited to welcome Nick Weber to today’s podcast, which is looking back at ‘25 and looking forward to ‘26. Welcome, Nick. Great to have you on the show.

Nick Weber: Richard, thanks for having me. I’m very excited to be here. This is my first podcast. So, you know, go gentle.

Richard Leaver: Absolutely. Well, Nick, the reason I wanted to invite you to really look at the year in review and looking forward is because you’re an industry leader, you’re the CEO of Team Rehab, and I’ve always has been very impressed with regards to your perspective to outpatient therapy and really the culture that you’ve built with your team. So thank you so much for agreeing to be here today.

Nick Weber: No, thank you, Richard. I really appreciate that. I’m a very proud Team Rehab member and part of that earlier wave. And I can’t thank you enough as being a young executive running into you at the Ascend conference who you followed one of those awful hinge or sword perk people and got up there and I wasn’t sure what to expect in the room because it’s my first time there. And you got up there and I was like, wow, I don’t really like what that last person had to say. And then you got up there and basically slapped us all to wake up and the rest is history. Here we are.

Richard Leaver: Well, it’s funny you say that because I never actually got feedback from that session and I didn’t get many people come up to me and thank me. So the fact that it was perceived as a slap probably, probably is the reason enough why perhaps people didn’t rush up to me. But anyway, moving on! So 2025 – outpatient PT just seems to be a crazy, crazy world. And ‘25, I think is really no different. But I’d love to perhaps talk about what you saw in ‘25 as perhaps the main challenges and then some positives as well, because it’s easy to focus on the negatives, isn’t it? As outpatient therapists, we are continually and leaders at that. We’re continually focusing on what isn’t working well, but along with the main themes and challenges, certainly want to focus on some positives. So love your thoughts.

Nick Weber: Yeah, I think 2025 was from my lens. First of all, my lens is always a little bit glass half full. I’m always looking at the brighter side of things as much as I can. And for me in 2025, I actually kind of wind the clock back to the end of 24 because I went from being the chief operating officer in September to the CEO. And so my first 12 months was, you know, quite a whirlwind. I kept the CEO position and leaned on my team really, really heavily because I’ve got some great people and I had some help on the back end as we kind of worked our way through. And I think the way I look at 2025 is for the industry and for our company, it was a real great year. And I’m super high on outpatient PT. I mean, I love it, I love it. I’m very biased to say that it’s the best part of PT, but I think for 2025 we faced a lot of our challenges head on and they’re no stranger. This is no secret as to what I’m going to say. The challenges were – it’s margin compression from whatever side you want to look at it, and definitely keeping up with hiring and training the best people at a clip that meets the demand. And I’m really happy with the way our team came together and the recruiting seems to be coming in a much smoother direction. For our metrics, we wound the year so far net positive in hiring. We have more hires than we had in ‘24 and ‘23, so we’re kind of getting over that. Still competitive. It’s still really, really hard to find good people and enough people. So that’s still our number one challenge, is that demand. But I really think the industry is starting to iron itself out and we’re seeing it go in a much, much more sustainable direction in terms of how hiring is going. But that to me is kind of the best thing we’ve really started to overcome in 2025.

Richard Leaver: Yeah, I feel I could be eating my own words in 12 months’ time with this statement. I could certainly put myself in jeopardy. But I feel as if the tide has turned a little for ‘25. If I had to sum it up is the fact that we’ve been battling, I think really for a few years, certainly since COVID if not before COVID but certainly since COVID. And I feel as if we just got a little bit of relief in ‘25. I don’t know whether things necessarily improve. I’m not sure if they’ve improved or whether they didn’t continue to get worse. I suppose the glass half-full, glass half-empty perspective there, but I feel as if in some respects we’ve got a little bit of a reprieve. I won’t say that the tide has either started to go out or come back in, but I feel we’re on the cusp really. And my thoughts on that is from an advocacy perspective. I feel as if we’ve strengthened our voice in ‘25 significantly from a reimbursement perspective, whilst we’ve been knocked sideways with a couple of payers overall, I feel as if payers are realizing that they’re going to have to acquiesce to at least some sort of increase for us overall because they’ve squeezed us for so long. And then really the other thing which you touched on was the kind of the recruitment and I feel the great resignation is over. So whilst recruitment is still extremely tough, will continue to be tough. I feel at least the retention component, which is half of it, has perhaps settled somewhat. What are your thoughts on those components?

Nick Weber: Yeah, if we start with where you ended the recruitment and the retention is certainly gotten a lot more attention from our perspective in terms of really trying to make sure we’re much more intentional about how we recruit, onboard, train, advance, and maintain the talent that we’re able to get. We’ve definitely invested a lot of time and energy in trying to really make that onboarding full of touch points to make people feel like they’re part of something early on, whether it’s skills classes, post operative classes, internal classes where we’re bringing people who are brand new to the company together, whether they’re five, 10 years out or two, three months out to try to give them their community, their kind of sense of belonging and kind of get to know somebody. And we’ve really tried to make sure that there’s structure and touch points throughout those first 90 days, 12 months where they have opportunities to speak and know what to expect, but also have the opportunity to speak up and out about how that process is going versus what it was perceived and then we can listen to that and make that feedback. That’s been something that’s been very intentional and I think it’s been a part of our help. The other part that goes into retention is compensation which comes from. We only get paid from one way. We get paid by patients, whether it’s the patient insurance, it’s the patient providing us with cash or some other payer that’s tied to the insurance. So making sure that we’re driving our value and not devaluing our services at every opportunity through advocacy, through public relations, through education with our patients, I think that’s been a really strong point for us to not give away so many services and definitely discuss the value of what we’re able to do with our patients, which we’ve always done. But now more externally on an advocacy at a local, state, and national level. By doing that, I feel like that’s helped stabilize that margin compression a little bit. So instead of getting, you know, all of our money from insurance, we are getting and providing services that are valuable and are paid with cash in addition to that. That model, not just being a cash-based PT program, because that’s completely different, but in that insurance model kind of providing value that’s not paid by insurance, I really think has made a big difference in the perception of our value, which again helps lead to that retention.

Richard Leaver: Yes. What I think is for certain external stakeholders, legislators, and payers, whilst we haven’t necessarily been particularly successful with regards to moving the needle significantly as it pertains to reimbursement rates or offsetting Medicare cuts, but what I think the conversation has done is at least made them aware of value and made them aware that we’re no longer as a profession going to lie down and continue to take cuts. We cannot sustain the status quo and we have, as you say, margin compression to the point where a lot of smaller entities are having to fundamentally change how they’re operating or literally shut the doors. So I think they are hearing us, which to me is half the battle. Whereas perhaps in prior years and up until this point I don’t know that even the right people were in the room and whether they even heard any messaging.

Nick Weber: Yeah, I agree. I, I was recruited to kind of show up, to kind of back up things that I wanted to see done. And I dove into advocacy here in Michigan and volunteer a little bit and that and spending time with you and others on APTQI. I’ve really understood what it’s like to fight at a national level for our value. And I do feel we’re getting heard. And I think what’s great is we’re taking our real fractioned profession and starting to kind of piece it together through formal alliances and, you know, informal alliances. We’re really starting to strengthen our voice and I do think it is starting to make a difference on a, on a national stage. And I think that the value proposition that we’re leading with and we’ve frankly already demonstrated is going to be hard to be ignored. I mean, the value of PT first or PT early or PT first for MSK or realistically, whether we’re primary care, MSK or primary care down the road, that’s where we’re Starting to gain a foothold and there’s some really exciting things going on across the country that is allowing us to get to that point. And Richard, you and I have talked about how we’ve provided value in these total joint bundles in some of these national value based care. The evidence is there and it’s just a matter of us kind of continuing to show our value. And I think if we don’t get it by going directly to insurances, we’re definitely going to get it by going to the people who either need the care or are providing the benefits for the patients who use their insurance to come and see us for their services.

Richard Leaver: Absolutely. What have you felt has been the difference? And I think we’ve touched on some of the themes but love your perspective and what you feel. Perhaps the difference between 2024 and 2025 was. I don’t think there’s necessarily any paradigm shifts, but I definitely feel, I’m feeling very different personally today as a CEO of and of the organization than I was 12 months ago, for instance. And I’m sure you’re probably in a similar place to that as well.

Nick Weber: I agree. I think your idea about the tide shifting and kind of wondering is it coming in, going out and that. But it has shifted. And I think for us in 2024, we were still trying to get our footing on all the things that were compressing margins and we had some doom and gloom from payers on the horizon that we were trying to prepare for. So we had a lot of preparing to make the changes that we needed to make in order to stay competitive with our compensation for our employees and be resources in our communities for access to as many insurances as possible. So it was a lot of preparing and posturing where we took a lot of action. We, you know, initiatives for, you know, cash pay services and clinics. For us, for instance, for cash pay clinics and service was, was a big deal. We’ve had an increase in some musculoskeletal technology that we’re trialing for a company which has been a lot of fun for clinics to, to be a part of, kind of a cutting edge and then other things like really buying in on the value for some of the technology that’s out there in terms of our AI, for our scribing technology, for patient experience and even for the RTM. We’ve been able to launch a lot of those in 25. So we’re taking that action. In ’24, we were kind of prepping and dealing with ‘25. We were really able to take that action. And I think that feels good because we’re seeing the movement going forward as a profession and certainly within our company.

Richard Leaver: Yeah. However painful I think some of these changes have been or these challenges have been, it has been a catalyst, hasn’t it, for organizations to double down on change. I know there’s constant change in healthcare, but I feel as if it’s certainly focused us. And the companies that are reasonably strong, I think have done a good job over the last 12 months with implementing changes to counter those challenges that we’ve had over the last few years. And certainly see that when I look at USPT and some of the tactics and some of the initiatives they’ve done. And to your point, early, really changing, perhaps, or enhancing how we have onboarded and managed employees. So I think the rubber kind of hit the road in ‘25 with regards to, instead of being on our back foot, we’ve actually managed to get a little bit of traction to offset some of those prior challenges. Yes.

Nick Weber: Yeah. And I think keeping to the key principles of, at the end of the day, this is a people business. We take care of people. They come to us at a point where they’re asking for help, which is hard. They come to us when they’re not well, which is that’s not probably the least likely fun time they’re having. And it’s such a rewarding profession. So keeping that motivation and energy up to be focused on the patient while all the variables around, what it takes to take care of them and take care of each other, the people on the team who are doing that, keeping that in focus and watching the amazing talent of how these therapists and people behind the scenes kind of bend over backwards and dodge all these haymakers that come from payers or other environments external to the clinic is nothing that shouldn’t be taken for granted. And I think being able to adapt and keep your NPS scores, keep your outcome scores up through all that turmoil is quite a testament to the profession. And it’s good to see that big companies who do publish their data, like USPH, they’re keeping their patients first. And it’s good that this profession through all this is keeping its patients first. And we’re just adapting a lot quicker than we used to, and it’s pretty impressive. So maybe that’s what it is, Richard. Are we just adapting quicker? You know, from, from 2020 to now, like we’ve gotten, I don’t want to say used to the pace of change, but maybe can keep up a little better. What do you think?

Richard Leaver: I think that’s probably pretty accurate to be honest. People on the whole, aren’t they reluctant to change? But we’ve had to, we’ve had no choice. And certainly the speed at which we’ve changed. I don’t know if I’m just getting older, but I feel that every year the speed of change seems to increase. And healthcare, I think with the changes that have occurred at the macro level, both economic and also political, they’ve just been buffeted. And I think we’ve had to learn how to protect ourselves very quickly. And those that have learned that or learned the lessons I think are in a much stronger position for it, currently.

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Richard Leaver: Moving on a little bit. What I’ve experienced the last 12 months is that non-clinical staffing seem to get significantly easier to retain and recruit for compared to two, three years ago. But clinical staffing still remains tough. I believe that the retention component is better, but recruitment is still extremely difficult. Is that what you’ve experienced? And also do you get any sense that that might change in the next 12 months?

Nick Weber: Yeah, I still think what I’m happy about 2025 for is we definitely improved our retention and our overall retention to recruitment overall has improved. We’re still not retaining people like we did pre-2020, but I don’t think anybody is. But it certainly was quite a shock to our system. And I think that the hard to hire areas are still going to have always been and will always be the hard to hire areas. Finding licenses in remote areas is difficult. So you know, attracting students, growing your own from Tech to PTA to PT, that’s how you, how you can really be intentional about filling staff vacancies. And they’re definitely more important than ever in these hard-to-hire areas. I do see the landscape shifting a little bit and this is in a direction I don’t love. I was, you know, we used to only really recruit against people who wanted outpatient. We were just recruiting against other outpatient companies. Right. I’ve definitely seen a resurgence in people, new grads going to hospitals, long-term care and home care. And I think a lot of that is the blessing of or the curse of Medicare Advantage coming back to pay strongly for those services as they continue to punish us on the outside and in private practice. But it’s a subtle shift. But I mean, as far as I’m concerned, that’s those are not apples to apples. So we have to really put ourselves forward to show why private practice and outpatient PT is the best place for therapists because of the variety and value you can bring. So as far as the shift goes, I think we’re going to continue to have challenges, but I think we’ve got a much better beat on how to be successful and I think that success is going to continue as we move forward.

Richard Leaver: That’s great. Obviously there’s been persistent increases in operating costs. We just mentioned kind of margin erosion or trying to prevent margin erosion. Optimization has become much more important and a focus for many organizations, including ours. Has this been an area of focus for Team Rehab? And on a very practical level, when we talk about optimization, what types of things have you explored or implemented to help with that?

Nick Weber: I think that for us, we underwent a very purposeful transformation project where we knew we had to deal with change quickly and we needed to make sure communication was heard throughout, not just top to bottom, but, you know, front to back, side to side, and bottom up. And we went on a journey of making sure we had ways to create communication touch points throughout the organization, simple things that we were focusing on each week. And we had a feedback loop within the clinic and external to the clinic to make sure everybody understood. So when we had to make a change or an optimization, it was well communicated, or I shouldn’t say well, I should say better communicated than in the past. And I think that it also generated a lot of good feedback and ideas. So it forced us to listen to what was needed in the clinics. And the number one thing that was needed was help with documentation. Nobody likes writing notes, nobody has, nobody ever will. Once you think you get it right, the payer tells you you got it wrong. So the scribing technology we used through our EMR partner has been an absolute game changer for us. That was our biggest focus is not only getting it rolled out, but getting it optimized so that, you know, not just our laggards were getting help to get that giant monkey off their back, but that people who were doing it well just got more efficient so they could just have more time with patients and you know, less time outside of work worrying about notes. So that was, that was the biggest and best thing we’ve done. The other thing we heard is in response to finding really, really good non-clinical help those we call them patient access coordinators, those people who work the front desk and are the first voice and face that people see. We want those people to be focused on that stuff, not all these reports, not auto generating auths and referrals. So we really work to pull anything non-patient facing, either automated or assisted in any way we could, so we could just keep them dialed in with what they’re doing. And that’s what we’re. These people want to do, they want to interact. So we want to increase as much of that as we can. So those are our two big intentional pieces at the clinic and centrally we work to leverage technology as much as possible. Even from we went from using Google, our Google suite just maybe 5, 10% to maybe we’re up to using 20, 25% of its capabilities. But it has been outstanding what it’s been able to do for us. And the same thing with looking at all of our central functions to try and get them a little bit trimmer. And we’ve had great return from our central team looking at the way they do their work using that transformation communication process to give us ideas on how to make the process better and where we can, we make them. And it has kind of cushioned that burden a little bit. But it’s that compression is real for margins for sure.

Richard Leaver: Yes. I find that like yourself, we’ve implemented some technology solutions and I think this is just really the start. I feel that we haven’t necessarily seen a significant return on it yet from a financial perspective. I definitely seen I think improvements related to reducing error rates, satisfaction perhaps. But I have a feeling then the next year or two as we go further down the road of technological enhancements or applying it to both the clinical and non-clinical that I think we will see some true financial optimization associated with it as well.

Nick Weber: Yeah, and I think that the other part to this is by having more touch points throughout the organization, I don’t want to say forced interactions, but making sure people were having not just interactions but the right interactions with the right few key points was important. What it also identified was we needed to have more training for our leadership team at all levels in the clinic and certainly centrally. So recognizing that gap and beginning that with realistically it’s only really begun in this last few months, but setting up more formal training for people who don’t necessarily want to be clinic directors, but still want to be leaders in the clinic, really firming up those clinical pathways for success, really important. But also training new managers on the RCM or in the finance side how to be managers. That’s also been valuable because it’s. We need to grow our own leaders and we want to make sure people really have the tools they need to succeed and grow with our company, which is important to us.

Richard Leaver: Moving on a little bit when we look at growth. And I think the whole conversation around growth has to be framed. So as a clinician, when you talk to a clinician about growth, they just perceive it as an entity wanting to fill their pot of money in the corner of a room or. But it’s furthest from the truth, isn’t it? Definitely, I believe the saying grow or die, it sounds a little extreme, but certainly in healthcare, if you’re not growing, then you aren’t necessarily getting economies of scale and you are not able to continue to provide for the team members that you have with the resources, support and compensation that we need to. So I think it’s an imperative to grow. But how organizations grow, I think varies tremendously for various factors. And each year I think the primary method of growth can vary. So for instance, we have same-store growth, we have building new clinics and then we have new partnerships. And whilst I appreciate this perhaps isn’t as applicable for the single clinic owner, but I think for our organizations generally it’s how do you grow and what’s your thought as it pertains to kind of 2026 with regards to how should organizations be looking at growth? What perhaps are the methods or the levers of growth going forwards?

Nick Weber: I think that you’re spot-on about the average therapist or the average employee looking at growth as maybe not not the most positive thing. And I think establishing the why behind the growth for everybody so that they understand that if we can grow, this is what provides compensation to help us attract the best people. And as we grow, there’s more opportunity for you to grow and more opportunities for upward mobility within or obviously without the organization. But establishing that why is super important early on. And for us, our method of growth is tied strongly to each of our clinics – currently 136 – have ownership at that local level. And we’re looking for people who want to own and create a patient environment that is really positive. So we want to develop that talent internally and then give those people the opportunity to have ownership. You know, every once in a while, we’ll get a current clinic director to grumble, oh, why are we adding all these clinics? I’m like, hey, you remember when we gave you a clinic? You know, you were in a clinic and you went through training and you went, you expressed like you wanted a clinic. This is to give you the next you the next opportunity. And, you know, don’t we want that for everybody? And, you know, having those conversations and really establishing the why is important. So for us, it’s De Novo growth when we are looking to invest in people. You know, the people who are great therapists who have a passion for the profession and are just hungry for, you know, autonomy and entrepreneurship. And then for us, it is about same store growth. You know, we. We keep our focus narrow. And I think same store growth is important because within your population and within your four walls, there’s all kinds of great things you can add. Like we talked about it earlier, you know, cash pay, RTM, other services like that. So even same store growth can add referral sources. Niches is something we’re hopeful that we can get spread across because there’s such a demand for pelvic care, pelvic floor care, vertigo, concussion, all of those things. And we want to make sure we provide those opportunities for therapists who want to take them. So same store growth in De Novo is, you know, where we put our growth mode into.

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Richard Leaver: Now, as a clinician, we’re both clinicians. You know, the reason I went into therapy was to help people, and the more people I can help, the better. But I feel that certainly in ‘25, we’ve experienced some challenges to same store growth, and that’s not because of demand for services. It’s because of staffing the clinics to be able to allow for that growth and be able to help more people, which is really quite a change to 10 years ago, where when we were looking at same store growth, we were really looking at how do we increase referrals. Whereas now when we look at same store growth, I think the primary challenge is how do we staff to allow it to occur. So definitely a shift there. Have you – well, based off our conversation, I would imagine that you have experienced some challenges with regards to same store. Certainly in those locations that have had challenges associated with recruitment, yes?

Nick Weber: Yeah, I think planning for growth is great. And just like any great plan, it’s great until you get punched in the mouth. Right. And you know, having therapist hours to treat the patients and take care of those people in the communities you serve is, is job one. And you know there’s gonna be staff changes, you know, heaven forbid, there’s all kinds of medical issues that pop up. I mean, we, you know, it’s no surprise that you can lose hours for all kinds of reasons. So growth and profitability are so tied to having people, the patients and then the people to take care of the patients. So we’ve definitely run into hard-to-hire areas where we can see visits just plummet for no other reason other than there just isn’t enough hours in the clinic. And at that time that focus, as much as it has to be as to taking care of patients, you can’t take your eye off the ball about taking care of your current staff, but making sure that you’re focused on them, them and their needs to make sure that they can deliver the care that’s best. And then focus on making sure you leverage all the tools that you have at your disposal to get those bodies. And then once you get those bodies in, you know, do a good job of keeping them and that’s the best you can do. But you’re right that that has definitely been more of a curveball for how we forecast. You know, you can’t, can’t forecast for 50 weeks of a therapist anymore. You certainly, you know, 48, maybe even is as brave as you can go, but it does definitely cause a non-linear growth model for sure. Yes.

Richard Leaver: Turning towards ‘26, I’m actually quite bullish and I’m definitely the glass half-empty guy in the room. I feel that we will continue to build on the conversations and the, the wins of ‘25. Personally, do you feel bullish on ‘26 and what do you perhaps see on the horizon?

Nick Weber: Quite bullish on ‘26? I think with all the planning and thinking we did in ‘24 and the implementing we’re doing in ‘25, those lessons that we thought hard about and implemented in ‘25 are looking really good for ‘26. And as a reflection of that externally on the profession, I see nothing but the demand continue. I think that all these, pardon my language, pretenders in the space are trying to fill in a void that we can’t right now. And the more that we as therapists find ways to fill that void. It’s going to continue to lead to furthering of the profession and respect for the value that, that we provide to the entire healthcare system. So I’m very bullish on us continuing to kind of carve or force ourselves into the primary care MSK space for sure, but certainly the primary first stop for any MSK injury in any way, shape or form. I think we’re going to continue to gain momentum in that space. I think it’s a way we will be able to get around having to deal with insurance not paying us more. And I really think that’s our passion for the future. And I think it’ll start to match what therapists want to do, which is focus on taking care of patients not just when they’re hurt, but before they’re hurt. So I’m very bullish on the profession moving in that direction and that’ll also facilitate us being able to be less dependent on the whims and feelings of payers.

Richard Leaver: I always finish up asking if there’s any other words of wisdom. I’m sure that you have plenty of wisdom, but anything else to share perhaps with the audience as we wrap this up?

Nick Weber: Well, certainly not as much wisdom as you, Richard. And again, I really, really do appreciate the relationship we’ve had and how open you’ve been to not just answering questions, but being open to ask me for questions too. Because the best way you learn is it’s a two-way street and you get to learn from not just the person you’re seeking the knowledge from, but them seeking some knowledge and clarity from you. And I do appreciate that. And as far as my wisdom, I think I-like you-I got into this profession to help people and I really haven’t taken my eye off that ball ever. You know, I was definitely the therapist who squeezed everybody in and you know, worked around them and did all that. Cause I loved it and I still love it. And when I owned a clinic, I wanted to make sure I hired people who felt the same way, people who could complement my skills. So if it was something I couldn’t treat, you know, I could give it to them. That way we could, we could continually take care of more people. And with each of my roles, I feel like I’m still taking care of people and I just get to do it at a much bigger scale. So I think that the best thing here that I want to make sure we all do is just stick to fundamentals. We have a super rewarding profession. It is such a great field to be in and we get to help so many people and we get such instant gratification out of what we do and it’s exhausting and you need to take care of yourself. But I love this profession. I think we do great things and I think we’re poised to take bigger steps to asserting our value and getting more of the respect that we deserve. That’s been absent from anybody other than patients for, say, coming up in 2026. So I’m very bullish and no surprise, glass half-full for our profession going forward.

Richard Leaver: Thank you so much Nick for providing your perspective and thoughts for the ‘25 and going into ‘26. Thank you for your leadership and also your advocacy for the profession generally. It’s quite inspiring. So I wish you well over the next 12 months and perhaps in 12 months’ time we sit down and have a beer and work out what actually happened compared to what we think will happen. So thank you.

Nick Weber: Thank you, Richard.

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