Join Michelle Collie, CEO of High Bar Physical Therapy, and Richard Leaver in an engaging discussion on the future of outpatient therapy. Explore key topics like employee value, reimbursement challenges, staffing shortages, and expense control. Michelle shares insights from her leadership journey, offering a fresh perspective on technology, innovation, and self-care for healthcare professionals.
This transcript has been edited for clarity and ease of reading.
Alliance Physical Therapy Partners and Agile Virtual Physical Therapy proudly present Agile&Me, a physical therapy leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
Richard: Welcome back to Agile&Me a Physical Therapy Leadership Podcast. I'm very excited, again in my British monotone voice, to welcome Michelle Colley. Michelle is the CEO of High Bar Physical Therapy, formerly Performance PT, and today's podcast is looking back on 24, which is pretty incredible considering it feels as if it only just started a few days ago and then perhaps looking at our crystal ball for 25. So this is one of my most fun podcasts that I get to chat with other industry leaders. So welcome, Michelle, excited to have you with me today.
Michelle: Thank you, Richard. It's great to be here and nice to see the meshing of two different accents come together and see what comes of our discussion about the year that we've had, which I often think of it the year of reckoning, so to speak, but I'm also excited to speak about what we can look forward to the coming year.
Richard: Absolutely. Perhaps for the listeners, give a little bit of background to yourself.
Michelle: Absolutely. I graduated with a Bachelor of Physiotherapy from the University of Otago in New Zealand 30 years ago. I grew up on a sheep farm there. And once I graduate, like many folks from down under, we want to travel, see the world. And I had the opportunity to come to the small but mighty state of Rhode Island, planning on staying here for one year, learning, traveling. Seeing what America was all about and then heading off to your homeland of England to spend some years, obviously I got stuck here, so to speak, got involved with graduate school, went from being at a hospital situation into private practice. And at that stage, I worked at a single private practice called Performance Physical Therapy as the clinic director. And 22 years ago, the owner of that practice was interested in transitioning out. I was the clinic director and at the time I was eight months pregnant. And I said, why don't I just acquire it from you? And somehow I got some SBA loans. I think it might've been from the mafia, some Italian bank up in the Italian district of, in Rhode Island and became a practice owner. When I was two weeks out from having my first child, since then I've evolved, I love our profession. I love being a physical therapist. I think we bring immense value.
I do think there's tremendous opportunities for us to behave more as doctors of physical therapy or practice at the top of the license. And I've been blessed with being able to be involved at a national level with our chapters. Being the president of our state chapter, being involved in a lot of advocacy work, doing whatever I can to support our profession post pandemic, we did bring on our first private equity partner. That was three years ago, rally day partners. We did that because I was looking for a way to support established practices to be able to take it to the next level, but yet still hold on to the magic of private practice, still hold on to the culture, the innovation, all the things that we have. And that's when we launched our platform and that was We had 14 clinics at that stage, we've since built, continued to build the structure processes so that we can continue to grow and evolve through new clinics, through investing in our current team, and through partnerships or acquisitions, recently partnered with Peak Physical Therapy in Massachusetts, a 10 clinic location, so we're definitely on that growth stage at this time.
Richard: Well, kudos to you. I know the journey as a foreign trained therapist is not an easy one to relocate to the United States and, and get licensed. I don't know about you, but I had to take English as a foreign language examination. So, so anyway, one of many stories. Great background and yes, your entity is very important and highly respected and regarded within the PT space. So excited to get your perspective on 2024. So it’s certainly been a rollercoaster ride. I think every year one can say that really, but I think 2024 has some differences compared to prior years. And I think positive differences, I believe, are signs of positivity. I'd love to get your perspective on how 2024 has been for your practice and when as your role, with the APTA and talking to many practice owners, perhaps the perspective of those that you have listened to as well.
Michelle: I'm happy to Richard. I like the fact that you bring up there are some positive signs that are happening and I always do believe we've got to look at it as a glass half full and any challenges are really opportunities. I know we've all seen that there's been consistent operational challenges with recruitment with admin burden with payment. However, I think there's a reckoning this year, and that we've actually come to terms and accepting that employee value proposition is really, really essential and important. And we need to invest in their staff. The cost of churn has escalated more than ever. And we've got to really listen and make sure we're creating the environments that the next generation wants to work in, which is different to you and I, Richard, and many others. And that's okay. I think we've also understood that payer dynamics are changing. We're hearing people much more willing to talk about payment, realizing that you can say no to taking contracts because you just can't afford to take contracts that don't pay the bills. There's been more transparency And just a lot more open conversations about practice owners being willing to actually even look at their contracts. And I think there's been professional evolution. I'm seeing there's more willingness for advocacy. There's stronger conversations going on in some more collaboration. I hosted a podcast two weeks ago. We brought in Bob Hall, who's the payment specialist that's been hired by APTA Private Practice. Tremendous resources, and myself and a couple of others. I think it's three, over 300 participants, and we were purely talking about Payment just at some of our local states and people actually having the conversations and evolving how they have, how we evolve the profession as well as payment. So I see people being more solution driven and accepting where we currently are and that we can't just sit back and play the status quo. And I think that makes me excited for next year.
Richard: You know, ever since I came to the States, and like yourself, we came across at a similar time. There's been challenges, headwinds every year, and reimbursement in real and relative terms has gone down significantly over the last, to be honest, ever since that time, but certainly in the last 10 years. I think that it's almost reached an inflection point. And what I mean by that is that the outpatient therapies, stand alone entities, have been squeezed to the point where you can't continue to operate and think in the old paradigm. And whilst that can be very difficult, it's kind of a who moved my cheese type of thing, is it? Whilst it can be very difficult and painful, I think it does create an environment where those that are forward looking will make that shift and that significant shift and we'll start to think not about how to just make incremental change but how can we truly change how we're looking at, be that how we treat staff, be that how we bill and get reimbursed, be that how we operate generally rather than just nibbling at the seams, the edges which is what we've done for so many years. Would you agree with that?
Michelle: I would 100 percent agree with it. I like your point that for many years, I do feel like we've been nibbled at the edges. Like how do I get a little bit more? How do I get a PT to see one more patient a day or a week? How do we get one more code rather than standing back and going, all right, this isn't sustainable anymore. How do we really get creative and create and solution driven and actually lead the way rather than being victims of the current system?
Richard: Yeah, whilst I'm all for change, trying to understand what those changes are is tough. But we'll talk about that a little bit as we go through.
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Richard: You bring up the very interesting phrase, employee value proposition. I, as an organization, I think culturally we're pretty aligned. It was kind of by PTs for PTs, but I think there has to be more than that. Again, I think there's had to be this step change in how we perceive, how we treat, how we value, how we develop employees, with five generations, potentially within the workforce, you know, we've had to spend a lot of time and effort looking at that, particularly in the last couple of years. And with the shortage, which we'll talk about, and I think in 24, those organizations that are successful have really, truly focused on that. Perhaps tell me a little bit about it. About this concept, employee value proposition, and what, what your organization has, has perhaps done from a people perspective.
Michelle: Yeah, it's, it's such an interesting word. A year ago, I didn't even know what employee value proposition meant. So it's something that our organization has really needed to lean in. Do a lot of listening and realizing you mentioned five different generations and respect that each generation has some different values that they're looking for and again, and except that's okay. Our job as employers and leaders is to create an environment where people can practice at the top of their license or be the best version of ourselves rather than sitting back saying, Oh, this is the kind of place we've got. If you want to work for us, great. If not, go somewhere else. So there's been this really change in mindset to make sure we are there to serve our employees, doing a lot of listening and realizing that we do have to look carefully at not just the compensation, And the benefits that go with it, but also the kind of feedback that people are getting. Also the clarity in the opportunities. I find that this next generation wants to see the different pathways and have autonomy in their growth and development, and be heard and be listened to. They may change their mind and go on different pathways, but that's what they're seeking, which seems a little bit different to it. When I was in my twenties where I felt like I was more of a hustler. So creating clarity on what the growth and development opportunities are, giving people choices, respecting the work life balance side of things. And then as employers are really looking at what we can do to provide the structure and processes to decrease the things that cause stress, such as admin burden. So I think the employee value proposition, it's a big picture. It's not just pay and benefits. It's how we communicate, how we give feedback, how we show the opportunities, how we stay engaged with our employees and underlying ensuring you've got a culture and that culture is about what behaviors you, how you expect everyone to behave at work.
For us, we have a clear four values that are so immersed into our performance reviews, into our application process, into all of our verbiage, and how we show up every day at work and how we behave is driven by those four values. And we expect everyone to behave like that, which adds to that employee value proposition and helps.
Richard: A lot to unpack there. Compensation benefits are table stakes. That's not going to differentiate you nowadays and younger generations. Whilst they've got large student loans and struggling financially, it's it's one of a multitude of factors they're looking for. And it's interesting. Your employee value proposition is very similar to our kind of People first mentality when you and I qualified. It was very much patient first focus on the patient. But I think the organizations had to gravitate away from that. And it's not a people tactic or strategy. It has to be culture, doesn't it? Everything you do, how you do it, how you communicate it is all about people first and foremost. Yes.
Michelle: There was a book and I remember being appalled when I heard the title of this book saying that patients come second. So 20 years ago, I'd be like, how could anyone think like that? And, you know, it was only in the last few years that I was like, of course, if you take care and support your people, then I'm not worried. The patients will get great care. If you have happy clinicians who feel valued and show up feeling really good, then they're going to give great care.
Richard: Yes, and I think a tangible example is we have started on the journey and it is a journey and with regards to focusing on our employees. Let's not say we didn't, but more so now in a more deliberate and robust manner. And net promoter scores have gone up from, 87 to 93. We haven't changed anything with regards to the patient facing side. Truly, it's all focusing on the employee side.
Michelle: It's an excellent point. I like the fact that you bring up things like NPS, because I think having this kind of data supports the next generation of leaders, for example, your clinic directors, who yes, you and I can sit here and say, Listen to your people, take care of them, but it's more how do you help the next generation of leaders understand the importance of how they're working with their team and seeing leading measures like NPS are ways that you can actually help them understand through data that, oh, it is really important that I sit down with my staff and listen to them and have a conversation and understand their goals and their objectives and create pathways so that they can be successful in the workplace.
Richard: Now, let's not kid ourselves, staffing is a huge difficulty for everyone, regardless of one's culture, and not one culture suits everyone either. There is this shortfall but I've seen some, even though there is a structural deficit of licensed PTs, I have seen some improvements in the last four, five years. 12 months, particularly in the kind of the non clinical roles, but also perhaps improvements in retention generally, the great resignation that COVID created seems to have, I believe, settled somewhat. Would you agree with that? And what are you seeing and what are your clinics that you advocate for and represent as an APTA board member, what are they seeing?
Michelle: Yeah, seeing exactly what you mentioned, and there was a recent study that came out just last month on the workforce which showed that there is still this 9.5 percent approximately vacancy rate in outpatients, but what's interesting to that it's not because of this big resignation. The big part is, is that vacancy rate is because of the growth. So practices are growing, but unable to fulfill it so it's not just because of churn or resignation. We're definitely seeing a decline in openings for support staff. So you're completely right. That's what's showing in the industry as well. We're still seeing 71 percent based on that study have openings. And I think we all aware now that's not going to change. So there is fundamentally a shortage, but some of that shortage is because of the growing demand and the opportunities. That current practices have in our growth for many of us, I know for us, I could say we could be growing at a much faster rate if we were able to hire more culturally aligned clinicians that want to work in our environment. But I definitely seen a significant decrease in in turn or we've seen a significant increase in retention. Some of that I believe is because of the change in the dynamics of the profession and communities as a whole, but I also think some of it is because we've evolved our ways to of ensuring that we're communicating and supporting our clinicians really well.
Richard: Absolutely. Where I see some of the improvement as well is, you've touched on it very briefly, is the reimbursement and for many years I was like a kind of a beaten dog in the corner where I just kind of gave up with regards to trying to fight for improvements in reimbursement, given the fact that we just assumed and accepted we were price takers. But I think the mechanics have changed, the dynamics changed somewhat, and we've certainly seen some, some improvements in reimbursement with commercial payers. Admittedly, they're pitifully low, but they are improvements, and I've had to kind of eat humble pie somewhat with my board members and teams, and acknowledging that we've made some progress or the start of change, which is good. And I don't get the feeling that we're being bullied quite as much just to accept lower rates. Again, is that a common theme and why do you think the payers are beginning to make adjustments, however pitifully low they are?
Michelle: They are pitifully low and I would agree with you, we have had some success this year. One of the questions I would ask, are we seeing a change this year because we're actually doing a better job of asking? It's amazing how many practices I speak to and they don't even know where their contracts are. Let alone having some process of actually communicating, developing relationships and negotiating. There's two parts to it. One is my question, are we just getting better at asking and learning that here's the kind of data to present in a format that can actually allow for some dialogue? So there's one part. Or are payers changing? And I don't think payers are changing because they don't work for us. They're there to serve those folks who buy their policies, the employers. I'm going to sound a little negative here, commercial players. We’re not their customer. So my belief is those pitiful increases are maybe as a way to say, okay, we'll throw you a bone. You finally asked, all right, we feel a little sorry for you rather than, we truly understand the value of your services. We're going to actually pay you appropriately, but you're right. Every dollar counts and we are seeing it around the country that there are different wins. I think we're doing a better job of asking.
Richard: Yeah, I kind of ponder this, which is really quite sad reflection of my life, perhaps, and why pay is improving, but hey, it's great, but I think there's a number of factors or potential factors. One is, I think, as you say, we didn't even ask before because we just assumed that they were going to say no for so long, they certainly don't make it easy to ask either. It's half the battle is actually finding somebody to actually talk to even by our email, but I think there's other factors. I think for the first time I'm hearing more and more and I'm advocating that entities, outpatient therapy entities strongly consider just getting out and network. Because as you say, the payers are servants to their members. So if you make life difficult for the members, which is a really sad thing to say as a clinician, because I want to help as many people as I can, but also I've got to be able to keep the doors open to do that. But I think the first time where I think there is at least a reasonable voice or the voice has reached a certain level. I won't say it's a huge voice, but it reached a certain level where payers just come out, ignore it. Then the other thing I think is commercial payers have had some really bad press. You know, UHC this year has been really battered by the press and, and quite rightly so. So I think there is a component of payers just acknowledging that they've got to treat their providers and their members a little bit better, generally, and then lastly, I like to think that it's To do with value proposition as well, certainly with self insured entities, the idea that we all know, and we've known since the 70s, that, that therapy is a cost saver relative to other types of care. And I think there again has reached a level within the US now where there is, sufficient understanding and acceptance that if you go to therapy, it's going to be cheaper than going to a physician and getting all this additional imaging and unnecessary or surgeries at a fairly early stage in after diagnosis. So I think it's probably multifactorial. And I think I have a feeling that this is just the start as well. I have, perhaps it's wishful thinking, but now that we're beginning to at least have conversations with payers, I think it will, generate more requests from providers.
Michelle: Couldn't agree more. I wish we could find something to disagree on, Richard. Couldn't agree more. I would add in, because you mentioned the self funded or self insured, that we need to talk to the employers, because it's the employers that are seeing their premiums continue to increase and looking for solutions. So their motivation is very aligned with what we're able, the value we're able to offer. And they are the ones, especially if they're just utilizing a payer as the administrator of benefits, they're in a position to not just change payment, but change the admin burden, change the co payment, change these other things that actually have an impact. So I agree like advocating to the payers. But we also need to get in front of the employers, especially those that are self funded and there's more and more in that position. And that I think is where we may find some opportunities for increased payment and decreased burden of administrative challenges we're dealing with.
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Richard: You and I both talked to a lot of private practice owners, uh, as, you know, within advocacy, but also as a leader of an entity that's looking to partner with others and we have seen in 24, 23, really since COVID, but certainly 23 and 24 was wage pressure, inflation, repressure on compensation. And that was quite significant. I think as a larger entity, We can weather it a little bit better. I don't say weather it well, but whether it a little bit better than the kind of the single shingle outpatient independent owner. And I think that that pressure is really being felt by the smaller entities and companies, compromise their ability to operate in a financially stable and manner. Are you hearing that from independent practices or have they been able to flex accordingly and create a practice and operation that's accommodated this?
Michelle: Yeah, I think we're in the northeast and so traditionally payment is low in this part of the country. There are not many single shingle practices left in our region. They've either merged and been acquired to a larger entity. And those who are more now in a single location tend to have evolved their payment to be cash only or be more niche practice. So it's, it's really sad to see because I think especially the single private practice has this opportunity to be innovative and creative and pivot much quicker than you or I can in a larger organization. So there are advantages and opportunities when you have a single practice or even two or three clinics. We're seeing a lot less of them in our region.
Richard: Yes, it's interesting. I made a note earlier about, I talk about cash based business and, and what's happened in the UK. I'm not sure about New Zealand or Australia. What's happened in the UK with the national health services, when there was a shortage of clinicians, it created actually the second market of private cash based business. And it’s now become extremely common for people to avoid the more traditional health care route, which in this instance would be the normal payer route, and actually just decide to pay cash because really in the last 10 years therapy has actually become a cash based business because the the level of copay and deductible and the amount that the patient has to turn to pay relative to the total cost of care has gone up to the point where really having insurance for some actually makes pretty much minimal difference.
Michelle: Yeah, I could see that being a way of the future or even the employer is saying we'll just pay directly. There's another alternative that have the employers pay directly for the PT services rather than it going through the insurance company.
Richard: Yeah, interesting. Yeah, I think what I'd perhaps like to know is, what are your thoughts as it pertains to expense control or managing expense, increasing expense going forwards as a business owner. Obviously nothing's getting cheaper. Inflation is still with us, even though it's significantly less, thankfully. But you know, PT school is not getting cheaper on the whole, cost of living is not getting cheaper. As a business owner, what do you feel that we can do in 25 and beyond to try and control this? And what initiatives have you rolled out or thinking of looking at, to really maintain a profit margin that is sustainable, really?
Michelle: I wish I had a major answer to this, Richard. It's a tough one. I think that it takes a lot of discipline and thoughtfulness and collaboration between your folks who are supporting recruitment, HR, finance, to be really real about the cost of business and the cost of labor. And you're right. Inflation has lulled, but with a change in administration, I had probably more questions about, yeah, some days I can be like, this could be great. And other days I could have this fear of it. Maybe it's not, I just don't know. So I think control what you can control.
Be really disciplined about understanding The costs, whether they, and if you are investing in something, will this turn into a long time operational cost, or is this a one time, like understanding the implications of decisions that you make, because it's really hard once you invest in something or add an expense line to remove it. So just being very careful and thoughtful. I do think for us is payment is something we're looking very closely at. So we're looking very closely at the innovation and not just the delivery of care, but how we're paid for it as well. And we've seen some nice results from some pilots that we've had. One is more a fee for an episode of care. And this is through an IPA and working on folks post knee and hip arthroplasty to really provide care and a hybrid between digital and brick and mortar so we can improve our efficiencies and move away from the fee for service. but more on an episodic. So looking at patient satisfaction, clinical outcomes, decreased admissions and readmissions to SNF, et cetera, after these surgeries and just getting paid as a bundled payment, but being more creative and innovative in how we deliver and our clinicians like it as well, because it does provide them more autonomy and practice at the top of your license. We need the outcomes, obviously. But do it in the most efficient way. We have another one which is all about actually preventing joint arthroplasties. Working very closely with an AC, ACO and a non surgical MSK doc. And because again of this more holistic approach to taking care of arthritis, we actually now have the research to show our value and see the significant decrease in joint arthroplasties.Which hasn’t changed our payment, but it's allowed us to collect some data so we can work on that. And direct to employer is our other big initiative. We're really going to lean into that to really look at ways to evolve the relationships we have with employers, decreasing admin burden and the benefit offerings as well as the payment side. So your point about how do we manage our expenses. I'm really trying to outgrow those expenses. We've been very disciplined about expenses, been really careful, but I've got to look at it in both ways and really get creative about payment. Because again, where we are, our reimbursement levels, we're getting little bits of increases, but it's not enough for me to feel good about how we compensate our clinicians because they deserve to be paid a lot more than what we actually can pay them at the moment. And I would love to be able to one day feel really good about the compensation packages that we provide our clinicians and that we did everything we could to ensure they were paid appropriately.
Richard: Yeah, really interesting points. It's funny you talk about prevention of joint replacements, arthroplasty. When I first qualified, I worked in a hospital where we basically had a joint boot club and every afternoon we'd be in the gym and lots of people with arthritis would come in.
And looking back, I'm sure probably we prevented replacement surgery knee and hip for about 25 percent of those patients. It just wasn't necessary. Be that weakness, be that low limb biomechanical dysfunction, be that tightness, or just immobility, just general immobility creating kind of chronic pain. So, that's very interesting. I also find the point with regards to expense control interesting regards to, I've always said you can't, can't be successful in managing and growing a business if you focus on expense wholly. That's not to say that we, we can waste. And I think where some companies, healthcare entities have slipped up is they've let the expenses run away from them a little bit. You know, for instance, if we save a dollar a day for every clinic, that amounts to many thousands of dollars each year. So even just like saving one dollar a day as a larger entity can have quite a profound impact cumulatively. But you're right, it's really revenue, focusing on revenue, focusing on how do we explain value, demonstrate value, demonstrating value. In a creative manner, isn't it? I love the ways that you're looking at that. If we change tact a little bit and perhaps focus a little more on advocacy because this I think is continuing to get traction and I feel that as a profession, and personally, I believe that it's primarily actually through the APTQI, but you know, that we are beginning to get a voice and I think for the first time ever actually a seat at the table and many tables. And I haven't been involved with advocacy at a national level until very recently. What has been your perspective in the last five years and how do you feel about advocacy and how successful we're likely to be or what, how do you see the journey continuing in the next few years for outpatient therapy?
Michelle: I think we're at a time that we've actually gained a lot of respect. I've seen it in Rhode Island, our small but mighty state. And so Rhode Island's little, so we know everyone. So I think it makes advocacy a little bit easier. But at a federal level, we've certainly seen some changes that are coming into place in the new year, some of it directly through CMS. But I'm sure some of it is because of the overall advocacy for some of the admin burden sides of things. The work that APTQI and APTA are both doing, I mean, APTQI is much more focused on outpatients, and we've certainly seen some relationship development happen that APTQI is doing. increase the awareness of our legislators and understanding the value we bring. So I think we've had, we have a louder voice than ever before because of these organizations, APT, APTQI, and there's a few others out there. It is just to set the expectation up that everyone has to be involved and you have to get these folks into your clinic to understand the value of what we do. And it's not just the leaders, it's your staff clinicians, it's your clinic directors, it's the students, but I certainly see it turning into more of a expectation that if you want to take care of our profession, you need to have a voice. And so it almost feels like a groundswell coming. And I don't know what the ultimate outcomes of that will be. It will be obviously the Medicare and federal payers, but as we know, that helps to lead the way for many of the commercial folks. I just think there's more voices, there's louder voices, and we all have to be involved rather than just a few select folks.
Richard: Yes, it's interesting that, as a leader, I'm probably sending out a company wide communications, specifically addressing advocacy need, at least once every six, eight weeks, if not more frequently, depending on the time of year and as I was employed with other entities, those entities never asked for me to be involved or express my voice or write to a legislature or provide templates and even if only a small percentage portion of my organization partners do that. It's still a lot more than I think has ever happened.
Michelle: And I don't think the day to day clinician or student understands the power of their voice. And it wasn't until I've made multiple visits to DC and sat down with lobbyists and legislators. that I actually heard from them. No, we hear you. We count up how many emails or phone calls, and the more we get, the louder your voice.
Richard: Yeah, that's critical. So pivoting perhaps, you've talked about alternative payment models and the term value based care is banded around and continues to be increasingly so, I think, in many areas of healthcare. But I've always struggled with the concept, and particularly when outpatient therapy, the cost of an episode of care is actually very low compared to other healthcare innova compared to say a spinal cord stimulator or neurosurgery. So I've always struggled with this concept of value based care. I would love to perhaps get your thoughts on what it means to you and how can we as a profession embrace that concept going forwards.
Michelle: It's a great topic because I believe in theory it sounds really good and I very much love the thought of payment based on value rather than the more you do the more you get paid. So I think that the terminology provides opportunities but there's lots of challenges with it. Because implementation of it in such a complex and fragmented system is really challenging, to your point about the spinal patient. Same with the surgery, we may be able to prevent a joint arthroplasty, but all a traditional payer is seeing is our eight to ten visits, and we're not getting any credit for the prevention of that surgery. I don't think we should ignore it though. I think it provides us to actually show our value, even if I don't know how we get paid for that at the moment. I think the opportunity aligns more with fully self insured or direct to employers because they will look at the whole package. But with traditional insurance companies, I'm really unsure how it can be actually integrated into the payment model. I know for us though, We lean in big time and make sure that we're being very thoughtful and standardized about our outcomes tracking, even just for that episode of care, looking at patient satisfaction, and then some of the partnerships we've developed, being able to gather information to be able to share that with payers to say, hey, this is what we're doing. Based on this relationship or this, we were able to prevent this many surgeries compared to what we saw a year ago. Or we were able to prevent this many folks post arthropostomy going to a rehab or SNF or readmissions. So we're in a place where we're We're not getting paid for value based, but we're actually being able to start demonstrating that, which has definitely piqued the interest of folks of going like, huh, so how are we ultimately figure out the payment for this? I don't have a solution, don't know that, but I think it's really important that we continue to lean in and have a seat at the table and figure out a way for that to happen in the years to come.
Richard: I think that's really interesting. That's perhaps enlightening for me because I've always thought, well, why do I want to pursue an approach when there is no obvious or immediate financial recompense for it because as a business owner, it's very difficult to implement things that are going to create it. Perhaps more work in the short term without that financial reward. But, I think you're right. We have to continue to demonstrate or do a better job at demonstrating in tangible, objective manner before the dollars will come.
Michelle: I would just add a little pointer to that too, is the, unintended consequences we've found by leaning into these opportunities is that the referral sources that we're working with, yes, they may be utilizing us for these kinds of patients, but it is escalated. And truly deepen the relationship to support the care for a whole lot more patients. Though, yes, we maybe have this focus on this one value base, whether it's post arthroplasty or preventing it for two different groups. However, it's opened up tremendous opportunities and other avenues as well.
Richard: Yeah, absolutely. Turning towards 2025, interested to hear what, what perhaps you think will happen and what perhaps is an organization you're focusing on. You know, for instance, I believe there's two primary differentiators in outpatient therapy. One is, one is about people. And in fact, the second one is about technology. So we're looking at some technology solutions trying to explore how we can complement our existing practice. And I think, you know, a lot of entities will buy an off the shelf technology solutions as they come along so that in 25, Personally, really that's kind of the focus area still for our organization to try and control expense, improve kind of revenue generation and take care, continue to take care of our employees as well. What do you see happening in 25 and beyond for outpatient therapy and perhaps, you know, what, what is as an organization, what's your focus?
Michelle: I would say for us, technology integration is absolutely high on the agenda and in all different ways, whether it's AI to support our ability to get authorizations and help with documentation or kiosks for check in or even for the patient experience.
Also how you get that right mix of in person versus hybrid care to compliment that. I do see us also evolving our care delivery in line with the innovation that would support those support the changes with payment. So that is very much about an investing in our people to ensure they've got the opportunities to practice at the top of their license, but also very comfortable with technology and not feeling threatened by it, knowing that it actually enhances their ability to take care of people.
Richard: Yes, there isn't much light between us. Is there any final thoughts or words of wisdom as it pertains to kind of outpatient therapy and for our listeners who primarily kind of independent outpatient therapy owners?
Michelle: First of all, if you're a leader or an outpatients. Take care of yourself so you can show up every day to be the best version of yourself, so you can stay adaptable and optimistic. We really have an amazing profession. We get to help people and we bring immense value to health care, so don't let yourself forget that. And if you start to forget it, go and meditate, go for a run, get some sleep, like figure out how to take care of yourself because we do bring tremendous value. So I think that's really important for all of us because it can really get exhausting and there are a lot of challenges, but move forward because what we have is physical therapy is something is something really special. I think the practice that practices that will thrive will really balance the tradition of what good care is about and the values and behaviors that drive that. The goodness of their practices, but they also have to be innovative and embrace new technologies, embrace the care models, you know, my final pieces of wisdom is just, is don't be complacent and sit back. Don't wait for the change, like lead it. And we might not always have the answers, but what an exciting time when we actually do have new technology advances, more people curious about innovation and how we deliver care and payment. And we all know deep down, we're seeing more and more research on the value of what we do. So all of us now at this time in our careers. We've got the opportunity to lead the way and really make a difference to the future generation. So be excited about that.
Richard: Great. Well, thank you so much for today. I really appreciate the conversation. I hopefully the listeners have as well. And, and, you know, I think in prior years, I think it's been kind of the glass half empty. So thank you.
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Podcast Transcript
This transcript has been edited for clarity and ease of reading.
Alliance Physical Therapy Partners and Agile Virtual Physical Therapy proudly present Agile&Me, a physical therapy leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.
Richard: Welcome back to Agile&Me a Physical Therapy Leadership Podcast. I'm very excited, again in my British monotone voice, to welcome Michelle Colley. Michelle is the CEO of High Bar Physical Therapy, formerly Performance PT, and today's podcast is looking back on 24, which is pretty incredible considering it feels as if it only just started a few days ago and then perhaps looking at our crystal ball for 25. So this is one of my most fun podcasts that I get to chat with other industry leaders. So welcome, Michelle, excited to have you with me today.
Michelle: Thank you, Richard. It's great to be here and nice to see the meshing of two different accents come together and see what comes of our discussion about the year that we've had, which I often think of it the year of reckoning, so to speak, but I'm also excited to speak about what we can look forward to the coming year.
Richard: Absolutely. Perhaps for the listeners, give a little bit of background to yourself.
Michelle: Absolutely. I graduated with a Bachelor of Physiotherapy from the University of Otago in New Zealand 30 years ago. I grew up on a sheep farm there. And once I graduate, like many folks from down under, we want to travel, see the world. And I had the opportunity to come to the small but mighty state of Rhode Island, planning on staying here for one year, learning, traveling. Seeing what America was all about and then heading off to your homeland of England to spend some years, obviously I got stuck here, so to speak, got involved with graduate school, went from being at a hospital situation into private practice. And at that stage, I worked at a single private practice called Performance Physical Therapy as the clinic director. And 22 years ago, the owner of that practice was interested in transitioning out. I was the clinic director and at the time I was eight months pregnant. And I said, why don't I just acquire it from you? And somehow I got some SBA loans. I think it might've been from the mafia, some Italian bank up in the Italian district of, in Rhode Island and became a practice owner. When I was two weeks out from having my first child, since then I've evolved, I love our profession. I love being a physical therapist. I think we bring immense value.
I do think there's tremendous opportunities for us to behave more as doctors of physical therapy or practice at the top of the license. And I've been blessed with being able to be involved at a national level with our chapters. Being the president of our state chapter, being involved in a lot of advocacy work, doing whatever I can to support our profession post pandemic, we did bring on our first private equity partner. That was three years ago, rally day partners. We did that because I was looking for a way to support established practices to be able to take it to the next level, but yet still hold on to the magic of private practice, still hold on to the culture, the innovation, all the things that we have. And that's when we launched our platform and that was We had 14 clinics at that stage, we've since built, continued to build the structure processes so that we can continue to grow and evolve through new clinics, through investing in our current team, and through partnerships or acquisitions, recently partnered with Peak Physical Therapy in Massachusetts, a 10 clinic location, so we're definitely on that growth stage at this time.
Richard: Well, kudos to you. I know the journey as a foreign trained therapist is not an easy one to relocate to the United States and, and get licensed. I don't know about you, but I had to take English as a foreign language examination. So, so anyway, one of many stories. Great background and yes, your entity is very important and highly respected and regarded within the PT space. So excited to get your perspective on 2024. So it’s certainly been a rollercoaster ride. I think every year one can say that really, but I think 2024 has some differences compared to prior years. And I think positive differences, I believe, are signs of positivity. I'd love to get your perspective on how 2024 has been for your practice and when as your role, with the APTA and talking to many practice owners, perhaps the perspective of those that you have listened to as well.
Michelle: I'm happy to Richard. I like the fact that you bring up there are some positive signs that are happening and I always do believe we've got to look at it as a glass half full and any challenges are really opportunities. I know we've all seen that there's been consistent operational challenges with recruitment with admin burden with payment. However, I think there's a reckoning this year, and that we've actually come to terms and accepting that employee value proposition is really, really essential and important. And we need to invest in their staff. The cost of churn has escalated more than ever. And we've got to really listen and make sure we're creating the environments that the next generation wants to work in, which is different to you and I, Richard, and many others. And that's okay. I think we've also understood that payer dynamics are changing. We're hearing people much more willing to talk about payment, realizing that you can say no to taking contracts because you just can't afford to take contracts that don't pay the bills. There's been more transparency And just a lot more open conversations about practice owners being willing to actually even look at their contracts. And I think there's been professional evolution. I'm seeing there's more willingness for advocacy. There's stronger conversations going on in some more collaboration. I hosted a podcast two weeks ago. We brought in Bob Hall, who's the payment specialist that's been hired by APTA Private Practice. Tremendous resources, and myself and a couple of others. I think it's three, over 300 participants, and we were purely talking about Payment just at some of our local states and people actually having the conversations and evolving how they have, how we evolve the profession as well as payment. So I see people being more solution driven and accepting where we currently are and that we can't just sit back and play the status quo. And I think that makes me excited for next year.
Richard: You know, ever since I came to the States, and like yourself, we came across at a similar time. There's been challenges, headwinds every year, and reimbursement in real and relative terms has gone down significantly over the last, to be honest, ever since that time, but certainly in the last 10 years. I think that it's almost reached an inflection point. And what I mean by that is that the outpatient therapies, stand alone entities, have been squeezed to the point where you can't continue to operate and think in the old paradigm. And whilst that can be very difficult, it's kind of a who moved my cheese type of thing, is it? Whilst it can be very difficult and painful, I think it does create an environment where those that are forward looking will make that shift and that significant shift and we'll start to think not about how to just make incremental change but how can we truly change how we're looking at, be that how we treat staff, be that how we bill and get reimbursed, be that how we operate generally rather than just nibbling at the seams, the edges which is what we've done for so many years. Would you agree with that?
Michelle: I would 100 percent agree with it. I like your point that for many years, I do feel like we've been nibbled at the edges. Like how do I get a little bit more? How do I get a PT to see one more patient a day or a week? How do we get one more code rather than standing back and going, all right, this isn't sustainable anymore. How do we really get creative and create and solution driven and actually lead the way rather than being victims of the current system?
Richard: Yeah, whilst I'm all for change, trying to understand what those changes are is tough. But we'll talk about that a little bit as we go through.
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Richard: You bring up the very interesting phrase, employee value proposition. I, as an organization, I think culturally we're pretty aligned. It was kind of by PTs for PTs, but I think there has to be more than that. Again, I think there's had to be this step change in how we perceive, how we treat, how we value, how we develop employees, with five generations, potentially within the workforce, you know, we've had to spend a lot of time and effort looking at that, particularly in the last couple of years. And with the shortage, which we'll talk about, and I think in 24, those organizations that are successful have really, truly focused on that. Perhaps tell me a little bit about it. About this concept, employee value proposition, and what, what your organization has, has perhaps done from a people perspective.
Michelle: Yeah, it's, it's such an interesting word. A year ago, I didn't even know what employee value proposition meant. So it's something that our organization has really needed to lean in. Do a lot of listening and realizing you mentioned five different generations and respect that each generation has some different values that they're looking for and again, and except that's okay. Our job as employers and leaders is to create an environment where people can practice at the top of their license or be the best version of ourselves rather than sitting back saying, Oh, this is the kind of place we've got. If you want to work for us, great. If not, go somewhere else. So there's been this really change in mindset to make sure we are there to serve our employees, doing a lot of listening and realizing that we do have to look carefully at not just the compensation, And the benefits that go with it, but also the kind of feedback that people are getting. Also the clarity in the opportunities. I find that this next generation wants to see the different pathways and have autonomy in their growth and development, and be heard and be listened to. They may change their mind and go on different pathways, but that's what they're seeking, which seems a little bit different to it. When I was in my twenties where I felt like I was more of a hustler. So creating clarity on what the growth and development opportunities are, giving people choices, respecting the work life balance side of things. And then as employers are really looking at what we can do to provide the structure and processes to decrease the things that cause stress, such as admin burden. So I think the employee value proposition, it's a big picture. It's not just pay and benefits. It's how we communicate, how we give feedback, how we show the opportunities, how we stay engaged with our employees and underlying ensuring you've got a culture and that culture is about what behaviors you, how you expect everyone to behave at work.
For us, we have a clear four values that are so immersed into our performance reviews, into our application process, into all of our verbiage, and how we show up every day at work and how we behave is driven by those four values. And we expect everyone to behave like that, which adds to that employee value proposition and helps.
Richard: A lot to unpack there. Compensation benefits are table stakes. That's not going to differentiate you nowadays and younger generations. Whilst they've got large student loans and struggling financially, it's it's one of a multitude of factors they're looking for. And it's interesting. Your employee value proposition is very similar to our kind of People first mentality when you and I qualified. It was very much patient first focus on the patient. But I think the organizations had to gravitate away from that. And it's not a people tactic or strategy. It has to be culture, doesn't it? Everything you do, how you do it, how you communicate it is all about people first and foremost. Yes.
Michelle: There was a book and I remember being appalled when I heard the title of this book saying that patients come second. So 20 years ago, I'd be like, how could anyone think like that? And, you know, it was only in the last few years that I was like, of course, if you take care and support your people, then I'm not worried. The patients will get great care. If you have happy clinicians who feel valued and show up feeling really good, then they're going to give great care.
Richard: Yes, and I think a tangible example is we have started on the journey and it is a journey and with regards to focusing on our employees. Let's not say we didn't, but more so now in a more deliberate and robust manner. And net promoter scores have gone up from, 87 to 93. We haven't changed anything with regards to the patient facing side. Truly, it's all focusing on the employee side.
Michelle: It's an excellent point. I like the fact that you bring up things like NPS, because I think having this kind of data supports the next generation of leaders, for example, your clinic directors, who yes, you and I can sit here and say, Listen to your people, take care of them, but it's more how do you help the next generation of leaders understand the importance of how they're working with their team and seeing leading measures like NPS are ways that you can actually help them understand through data that, oh, it is really important that I sit down with my staff and listen to them and have a conversation and understand their goals and their objectives and create pathways so that they can be successful in the workplace.
Richard: Now, let's not kid ourselves, staffing is a huge difficulty for everyone, regardless of one's culture, and not one culture suits everyone either. There is this shortfall but I've seen some, even though there is a structural deficit of licensed PTs, I have seen some improvements in the last four, five years. 12 months, particularly in the kind of the non clinical roles, but also perhaps improvements in retention generally, the great resignation that COVID created seems to have, I believe, settled somewhat. Would you agree with that? And what are you seeing and what are your clinics that you advocate for and represent as an APTA board member, what are they seeing?
Michelle: Yeah, seeing exactly what you mentioned, and there was a recent study that came out just last month on the workforce which showed that there is still this 9.5 percent approximately vacancy rate in outpatients, but what's interesting to that it's not because of this big resignation. The big part is, is that vacancy rate is because of the growth. So practices are growing, but unable to fulfill it so it's not just because of churn or resignation. We're definitely seeing a decline in openings for support staff. So you're completely right. That's what's showing in the industry as well. We're still seeing 71 percent based on that study have openings. And I think we all aware now that's not going to change. So there is fundamentally a shortage, but some of that shortage is because of the growing demand and the opportunities. That current practices have in our growth for many of us, I know for us, I could say we could be growing at a much faster rate if we were able to hire more culturally aligned clinicians that want to work in our environment. But I definitely seen a significant decrease in in turn or we've seen a significant increase in retention. Some of that I believe is because of the change in the dynamics of the profession and communities as a whole, but I also think some of it is because we've evolved our ways to of ensuring that we're communicating and supporting our clinicians really well.
Richard: Absolutely. Where I see some of the improvement as well is, you've touched on it very briefly, is the reimbursement and for many years I was like a kind of a beaten dog in the corner where I just kind of gave up with regards to trying to fight for improvements in reimbursement, given the fact that we just assumed and accepted we were price takers. But I think the mechanics have changed, the dynamics changed somewhat, and we've certainly seen some, some improvements in reimbursement with commercial payers. Admittedly, they're pitifully low, but they are improvements, and I've had to kind of eat humble pie somewhat with my board members and teams, and acknowledging that we've made some progress or the start of change, which is good. And I don't get the feeling that we're being bullied quite as much just to accept lower rates. Again, is that a common theme and why do you think the payers are beginning to make adjustments, however pitifully low they are?
Michelle: They are pitifully low and I would agree with you, we have had some success this year. One of the questions I would ask, are we seeing a change this year because we're actually doing a better job of asking? It's amazing how many practices I speak to and they don't even know where their contracts are. Let alone having some process of actually communicating, developing relationships and negotiating. There's two parts to it. One is my question, are we just getting better at asking and learning that here's the kind of data to present in a format that can actually allow for some dialogue? So there's one part. Or are payers changing? And I don't think payers are changing because they don't work for us. They're there to serve those folks who buy their policies, the employers. I'm going to sound a little negative here, commercial players. We’re not their customer. So my belief is those pitiful increases are maybe as a way to say, okay, we'll throw you a bone. You finally asked, all right, we feel a little sorry for you rather than, we truly understand the value of your services. We're going to actually pay you appropriately, but you're right. Every dollar counts and we are seeing it around the country that there are different wins. I think we're doing a better job of asking.
Richard: Yeah, I kind of ponder this, which is really quite sad reflection of my life, perhaps, and why pay is improving, but hey, it's great, but I think there's a number of factors or potential factors. One is, I think, as you say, we didn't even ask before because we just assumed that they were going to say no for so long, they certainly don't make it easy to ask either. It's half the battle is actually finding somebody to actually talk to even by our email, but I think there's other factors. I think for the first time I'm hearing more and more and I'm advocating that entities, outpatient therapy entities strongly consider just getting out and network. Because as you say, the payers are servants to their members. So if you make life difficult for the members, which is a really sad thing to say as a clinician, because I want to help as many people as I can, but also I've got to be able to keep the doors open to do that. But I think the first time where I think there is at least a reasonable voice or the voice has reached a certain level. I won't say it's a huge voice, but it reached a certain level where payers just come out, ignore it. Then the other thing I think is commercial payers have had some really bad press. You know, UHC this year has been really battered by the press and, and quite rightly so. So I think there is a component of payers just acknowledging that they've got to treat their providers and their members a little bit better, generally, and then lastly, I like to think that it's To do with value proposition as well, certainly with self insured entities, the idea that we all know, and we've known since the 70s, that, that therapy is a cost saver relative to other types of care. And I think there again has reached a level within the US now where there is, sufficient understanding and acceptance that if you go to therapy, it's going to be cheaper than going to a physician and getting all this additional imaging and unnecessary or surgeries at a fairly early stage in after diagnosis. So I think it's probably multifactorial. And I think I have a feeling that this is just the start as well. I have, perhaps it's wishful thinking, but now that we're beginning to at least have conversations with payers, I think it will, generate more requests from providers.
Michelle: Couldn't agree more. I wish we could find something to disagree on, Richard. Couldn't agree more. I would add in, because you mentioned the self funded or self insured, that we need to talk to the employers, because it's the employers that are seeing their premiums continue to increase and looking for solutions. So their motivation is very aligned with what we're able, the value we're able to offer. And they are the ones, especially if they're just utilizing a payer as the administrator of benefits, they're in a position to not just change payment, but change the admin burden, change the co payment, change these other things that actually have an impact. So I agree like advocating to the payers. But we also need to get in front of the employers, especially those that are self funded and there's more and more in that position. And that I think is where we may find some opportunities for increased payment and decreased burden of administrative challenges we're dealing with.
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Richard: You and I both talked to a lot of private practice owners, uh, as, you know, within advocacy, but also as a leader of an entity that's looking to partner with others and we have seen in 24, 23, really since COVID, but certainly 23 and 24 was wage pressure, inflation, repressure on compensation. And that was quite significant. I think as a larger entity, We can weather it a little bit better. I don't say weather it well, but whether it a little bit better than the kind of the single shingle outpatient independent owner. And I think that that pressure is really being felt by the smaller entities and companies, compromise their ability to operate in a financially stable and manner. Are you hearing that from independent practices or have they been able to flex accordingly and create a practice and operation that's accommodated this?
Michelle: Yeah, I think we're in the northeast and so traditionally payment is low in this part of the country. There are not many single shingle practices left in our region. They've either merged and been acquired to a larger entity. And those who are more now in a single location tend to have evolved their payment to be cash only or be more niche practice. So it's, it's really sad to see because I think especially the single private practice has this opportunity to be innovative and creative and pivot much quicker than you or I can in a larger organization. So there are advantages and opportunities when you have a single practice or even two or three clinics. We're seeing a lot less of them in our region.
Richard: Yes, it's interesting. I made a note earlier about, I talk about cash based business and, and what's happened in the UK. I'm not sure about New Zealand or Australia. What's happened in the UK with the national health services, when there was a shortage of clinicians, it created actually the second market of private cash based business. And it’s now become extremely common for people to avoid the more traditional health care route, which in this instance would be the normal payer route, and actually just decide to pay cash because really in the last 10 years therapy has actually become a cash based business because the the level of copay and deductible and the amount that the patient has to turn to pay relative to the total cost of care has gone up to the point where really having insurance for some actually makes pretty much minimal difference.
Michelle: Yeah, I could see that being a way of the future or even the employer is saying we'll just pay directly. There's another alternative that have the employers pay directly for the PT services rather than it going through the insurance company.
Richard: Yeah, interesting. Yeah, I think what I'd perhaps like to know is, what are your thoughts as it pertains to expense control or managing expense, increasing expense going forwards as a business owner. Obviously nothing's getting cheaper. Inflation is still with us, even though it's significantly less, thankfully. But you know, PT school is not getting cheaper on the whole, cost of living is not getting cheaper. As a business owner, what do you feel that we can do in 25 and beyond to try and control this? And what initiatives have you rolled out or thinking of looking at, to really maintain a profit margin that is sustainable, really?
Michelle: I wish I had a major answer to this, Richard. It's a tough one. I think that it takes a lot of discipline and thoughtfulness and collaboration between your folks who are supporting recruitment, HR, finance, to be really real about the cost of business and the cost of labor. And you're right. Inflation has lulled, but with a change in administration, I had probably more questions about, yeah, some days I can be like, this could be great. And other days I could have this fear of it. Maybe it's not, I just don't know. So I think control what you can control.
Be really disciplined about understanding The costs, whether they, and if you are investing in something, will this turn into a long time operational cost, or is this a one time, like understanding the implications of decisions that you make, because it's really hard once you invest in something or add an expense line to remove it. So just being very careful and thoughtful. I do think for us is payment is something we're looking very closely at. So we're looking very closely at the innovation and not just the delivery of care, but how we're paid for it as well. And we've seen some nice results from some pilots that we've had. One is more a fee for an episode of care. And this is through an IPA and working on folks post knee and hip arthroplasty to really provide care and a hybrid between digital and brick and mortar so we can improve our efficiencies and move away from the fee for service. but more on an episodic. So looking at patient satisfaction, clinical outcomes, decreased admissions and readmissions to SNF, et cetera, after these surgeries and just getting paid as a bundled payment, but being more creative and innovative in how we deliver and our clinicians like it as well, because it does provide them more autonomy and practice at the top of your license. We need the outcomes, obviously. But do it in the most efficient way. We have another one which is all about actually preventing joint arthroplasties. Working very closely with an AC, ACO and a non surgical MSK doc. And because again of this more holistic approach to taking care of arthritis, we actually now have the research to show our value and see the significant decrease in joint arthroplasties.Which hasn’t changed our payment, but it's allowed us to collect some data so we can work on that. And direct to employer is our other big initiative. We're really going to lean into that to really look at ways to evolve the relationships we have with employers, decreasing admin burden and the benefit offerings as well as the payment side. So your point about how do we manage our expenses. I'm really trying to outgrow those expenses. We've been very disciplined about expenses, been really careful, but I've got to look at it in both ways and really get creative about payment. Because again, where we are, our reimbursement levels, we're getting little bits of increases, but it's not enough for me to feel good about how we compensate our clinicians because they deserve to be paid a lot more than what we actually can pay them at the moment. And I would love to be able to one day feel really good about the compensation packages that we provide our clinicians and that we did everything we could to ensure they were paid appropriately.
Richard: Yeah, really interesting points. It's funny you talk about prevention of joint replacements, arthroplasty. When I first qualified, I worked in a hospital where we basically had a joint boot club and every afternoon we'd be in the gym and lots of people with arthritis would come in.
And looking back, I'm sure probably we prevented replacement surgery knee and hip for about 25 percent of those patients. It just wasn't necessary. Be that weakness, be that low limb biomechanical dysfunction, be that tightness, or just immobility, just general immobility creating kind of chronic pain. So, that's very interesting. I also find the point with regards to expense control interesting regards to, I've always said you can't, can't be successful in managing and growing a business if you focus on expense wholly. That's not to say that we, we can waste. And I think where some companies, healthcare entities have slipped up is they've let the expenses run away from them a little bit. You know, for instance, if we save a dollar a day for every clinic, that amounts to many thousands of dollars each year. So even just like saving one dollar a day as a larger entity can have quite a profound impact cumulatively. But you're right, it's really revenue, focusing on revenue, focusing on how do we explain value, demonstrate value, demonstrating value. In a creative manner, isn't it? I love the ways that you're looking at that. If we change tact a little bit and perhaps focus a little more on advocacy because this I think is continuing to get traction and I feel that as a profession, and personally, I believe that it's primarily actually through the APTQI, but you know, that we are beginning to get a voice and I think for the first time ever actually a seat at the table and many tables. And I haven't been involved with advocacy at a national level until very recently. What has been your perspective in the last five years and how do you feel about advocacy and how successful we're likely to be or what, how do you see the journey continuing in the next few years for outpatient therapy?
Michelle: I think we're at a time that we've actually gained a lot of respect. I've seen it in Rhode Island, our small but mighty state. And so Rhode Island's little, so we know everyone. So I think it makes advocacy a little bit easier. But at a federal level, we've certainly seen some changes that are coming into place in the new year, some of it directly through CMS. But I'm sure some of it is because of the overall advocacy for some of the admin burden sides of things. The work that APTQI and APTA are both doing, I mean, APTQI is much more focused on outpatients, and we've certainly seen some relationship development happen that APTQI is doing. increase the awareness of our legislators and understanding the value we bring. So I think we've had, we have a louder voice than ever before because of these organizations, APT, APTQI, and there's a few others out there. It is just to set the expectation up that everyone has to be involved and you have to get these folks into your clinic to understand the value of what we do. And it's not just the leaders, it's your staff clinicians, it's your clinic directors, it's the students, but I certainly see it turning into more of a expectation that if you want to take care of our profession, you need to have a voice. And so it almost feels like a groundswell coming. And I don't know what the ultimate outcomes of that will be. It will be obviously the Medicare and federal payers, but as we know, that helps to lead the way for many of the commercial folks. I just think there's more voices, there's louder voices, and we all have to be involved rather than just a few select folks.
Richard: Yes, it's interesting that, as a leader, I'm probably sending out a company wide communications, specifically addressing advocacy need, at least once every six, eight weeks, if not more frequently, depending on the time of year and as I was employed with other entities, those entities never asked for me to be involved or express my voice or write to a legislature or provide templates and even if only a small percentage portion of my organization partners do that. It's still a lot more than I think has ever happened.
Michelle: And I don't think the day to day clinician or student understands the power of their voice. And it wasn't until I've made multiple visits to DC and sat down with lobbyists and legislators. that I actually heard from them. No, we hear you. We count up how many emails or phone calls, and the more we get, the louder your voice.
Richard: Yeah, that's critical. So pivoting perhaps, you've talked about alternative payment models and the term value based care is banded around and continues to be increasingly so, I think, in many areas of healthcare. But I've always struggled with the concept, and particularly when outpatient therapy, the cost of an episode of care is actually very low compared to other healthcare innova compared to say a spinal cord stimulator or neurosurgery. So I've always struggled with this concept of value based care. I would love to perhaps get your thoughts on what it means to you and how can we as a profession embrace that concept going forwards.
Michelle: It's a great topic because I believe in theory it sounds really good and I very much love the thought of payment based on value rather than the more you do the more you get paid. So I think that the terminology provides opportunities but there's lots of challenges with it. Because implementation of it in such a complex and fragmented system is really challenging, to your point about the spinal patient. Same with the surgery, we may be able to prevent a joint arthroplasty, but all a traditional payer is seeing is our eight to ten visits, and we're not getting any credit for the prevention of that surgery. I don't think we should ignore it though. I think it provides us to actually show our value, even if I don't know how we get paid for that at the moment. I think the opportunity aligns more with fully self insured or direct to employers because they will look at the whole package. But with traditional insurance companies, I'm really unsure how it can be actually integrated into the payment model. I know for us though, We lean in big time and make sure that we're being very thoughtful and standardized about our outcomes tracking, even just for that episode of care, looking at patient satisfaction, and then some of the partnerships we've developed, being able to gather information to be able to share that with payers to say, hey, this is what we're doing. Based on this relationship or this, we were able to prevent this many surgeries compared to what we saw a year ago. Or we were able to prevent this many folks post arthropostomy going to a rehab or SNF or readmissions. So we're in a place where we're We're not getting paid for value based, but we're actually being able to start demonstrating that, which has definitely piqued the interest of folks of going like, huh, so how are we ultimately figure out the payment for this? I don't have a solution, don't know that, but I think it's really important that we continue to lean in and have a seat at the table and figure out a way for that to happen in the years to come.
Richard: I think that's really interesting. That's perhaps enlightening for me because I've always thought, well, why do I want to pursue an approach when there is no obvious or immediate financial recompense for it because as a business owner, it's very difficult to implement things that are going to create it. Perhaps more work in the short term without that financial reward. But, I think you're right. We have to continue to demonstrate or do a better job at demonstrating in tangible, objective manner before the dollars will come.
Michelle: I would just add a little pointer to that too, is the, unintended consequences we've found by leaning into these opportunities is that the referral sources that we're working with, yes, they may be utilizing us for these kinds of patients, but it is escalated. And truly deepen the relationship to support the care for a whole lot more patients. Though, yes, we maybe have this focus on this one value base, whether it's post arthroplasty or preventing it for two different groups. However, it's opened up tremendous opportunities and other avenues as well.
Richard: Yeah, absolutely. Turning towards 2025, interested to hear what, what perhaps you think will happen and what perhaps is an organization you're focusing on. You know, for instance, I believe there's two primary differentiators in outpatient therapy. One is, one is about people. And in fact, the second one is about technology. So we're looking at some technology solutions trying to explore how we can complement our existing practice. And I think, you know, a lot of entities will buy an off the shelf technology solutions as they come along so that in 25, Personally, really that's kind of the focus area still for our organization to try and control expense, improve kind of revenue generation and take care, continue to take care of our employees as well. What do you see happening in 25 and beyond for outpatient therapy and perhaps, you know, what, what is as an organization, what's your focus?
Michelle: I would say for us, technology integration is absolutely high on the agenda and in all different ways, whether it's AI to support our ability to get authorizations and help with documentation or kiosks for check in or even for the patient experience.
Also how you get that right mix of in person versus hybrid care to compliment that. I do see us also evolving our care delivery in line with the innovation that would support those support the changes with payment. So that is very much about an investing in our people to ensure they've got the opportunities to practice at the top of their license, but also very comfortable with technology and not feeling threatened by it, knowing that it actually enhances their ability to take care of people.
Richard: Yes, there isn't much light between us. Is there any final thoughts or words of wisdom as it pertains to kind of outpatient therapy and for our listeners who primarily kind of independent outpatient therapy owners?
Michelle: First of all, if you're a leader or an outpatients. Take care of yourself so you can show up every day to be the best version of yourself, so you can stay adaptable and optimistic. We really have an amazing profession. We get to help people and we bring immense value to health care, so don't let yourself forget that. And if you start to forget it, go and meditate, go for a run, get some sleep, like figure out how to take care of yourself because we do bring tremendous value. So I think that's really important for all of us because it can really get exhausting and there are a lot of challenges, but move forward because what we have is physical therapy is something is something really special. I think the practice that practices that will thrive will really balance the tradition of what good care is about and the values and behaviors that drive that. The goodness of their practices, but they also have to be innovative and embrace new technologies, embrace the care models, you know, my final pieces of wisdom is just, is don't be complacent and sit back. Don't wait for the change, like lead it. And we might not always have the answers, but what an exciting time when we actually do have new technology advances, more people curious about innovation and how we deliver care and payment. And we all know deep down, we're seeing more and more research on the value of what we do. So all of us now at this time in our careers. We've got the opportunity to lead the way and really make a difference to the future generation. So be excited about that.
Richard: Great. Well, thank you so much for today. I really appreciate the conversation. I hopefully the listeners have as well. And, and, you know, I think in prior years, I think it's been kind of the glass half empty. So thank you.
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