Transcript
stevenmc: Hello, everybody, and welcome back to another episode of The Disruptors, where we're highlighting innovators within the physical therapy community to help make innovation more accessible to everybody. Today, I'm so blessed to be joined by by Chad Madden. Chad is the founder of Madden Physical Therapy and the number one most watched back pain and sciatica specialist in the world. He grew up in West Hanover and graduated from Central Dauphin High School in 1995.
stevenmc: Joy to mediocre sports career in football, wrestling, and track. Realizing his strengths for an academics, not sports. He earned his master's degree in physical therapy at College Misericordia in Dallas, Pennsylvania. There he played four years of baseball, somement cementing his legacy as a mediocre athlete. On September 2nd, 2003, he opened Madden Physical Therapy with a total staff of one receptionist in a 2 ,000 square foot clinic on Prince Street.
stevenmc: and his oldest son was born three days later on September 5th. Chad's treatment schedule is limited today as he focuses much of his time and energy working with and helping other physical therapy owners across the US, Australia, and I think even more countries now. He's a co -founder of that company, Breakthrough PT Marketing. Chad currently lives in East Hanover on a three -acre farmette with his wife, Stephanie. They're five children, six sorry, six children, five mini donkeys, seven chickens, two cats,
stevenmc: a one -eyed boulder collie named Georgia. And I believe there's a llama in play or or two a couple of llamas in in play now as as well. But Chad, again, thank you very much for for spending some time with me and welcome to the what was are the disruptors.
Chad Madden: It's a huge honor, Steven. Thanks for having me.
stevenmc: i I kept having to laugh at the the mediocre athlete piece just because on my LinkedIn, the mediocre weightlifter is like one of the things that I have there. um And so, and I know you and I have have had some discussions at length about the the sports worlds and and triumphs and tribulations that we've gone through, but that is that is not for for here and now. That's a great bio and and a great start to this this conversation. um I would love to hear
stevenmc: your why behind getting into physical therapy. And then I think I love transition quickly into like, kind of why you, why breakthrough? Like, where's the passion that fuels you? I'm sure with the late nights and early mornings to be able to s serve practice owners across now, what is the the globe?
Chad Madden: Great. So the YPT is a simple one. When I was growing up, fairly good at math, entered competitions, and did a few things like that, and was very much fell into or pushed into the engineering pathway. Took a lot of engineering courses, and you know being semi -rebellious, 16 through 18, you know how it is.
Chad Madden: um i I was doing these courses, working with the very first AutoCAD one, two, and three, doing technical drawings, stuff like that. And, uh, and I went to the guidance counselor one day, Dale Halk, I remember was his name and I was like, Hey man, like, I don't think this is what I want to do. Can you help me figure this out? And he gave me a list of like top 20 in demand things. Physical therapy was number one or number two. So this is like mid nineties. And, uh, and he said, you should really volunteer.
Chad Madden: My mom had graduated with a therapist from high school. His name was Dale Hillbolt. He passed away, unfortunately, a few years ago. um But ah I went and started volunteering ah in Dale's clinic. And I remember there was a shoulder pain patient early on. And I just watched how this quickly this guy progressed in two or three weeks, could barely raise his arm. Two or three weeks later was back to normal. And I was like, wow, this is really what I want to do for the rest of my life. And yeah, just always fascinated with the human body and working with people and like has always felt like home.
stevenmc: Oh, that I appreciate you telling that story. And yeah, I can, I can hear and in your voice how how close Dale was to you. And, you know, a lot of, uh, we've had multiple guests talk about the mentors in their life.
stevenmc: And I don't know if you want to expand on that at all, uh, with, with your relationship with, with Dale, but I think that'd be helpful for, you were a volunteer, right? So unpaid volunteer.
Chad Madden: Yeah.
stevenmc: And and yet this sounds like he might have taken you under his wing or if you wouldn't mind talking a little bit about that.
Chad Madden: Yeah, I mean, he very much early on guided me in the right direction. You know, you should be thinking about this for colleges. Here's what you need to do using his network to get me into I think we had to have 40 or 100 hours of volunteer time. It was one of the other. um But they had to be in different settings. So just always make just in general, always looked out for me. There's there's a crazy part of the story, which is this. I actually went to work for Dale for about nine months prior to opening up.
Chad Madden: um it i did not It wasn't anything to do with him, but I had ah did not get along with somebody else in the company. um And my wife was very pregnant at the time, as you read in the bio.
Chad Madden: I was like, I need to make a move. Or if I don't do this now, I'm basically never going to do it. I had that in my head.
stevenmc: Yep.
Chad Madden: So ended up opening up. um Dale came to visit. And so like even though it didn't work out with his practice and I left, like he he checked in on me. He was an absolutely amazing person um and yeah just but one of those special people that everybody wants in their life. and Some of us are are lucky enough to have a few people like that.
Chad Madden: So yeah, he was he was great. um Even early on, um I was struggling with back this back pain treatment model that I had been taught. And he said, here's the researchers.
Chad Madden: Go find the research. Go look this up. Take this course. And I just followed exactly what he did. And it was it turned out to be literally life changing for me because that's what we built our practice on was back pain and sciatica.
stevenmc: ah Wow, that's that's fascinating.
Chad Madden: Yeah.
stevenmc: Thank you so much for for sharing that. It just keeps reinforcing the the point that we hear over and over again on here, especially. like Find a good mentor. And believe it or not, there are really good people that want to give back to you.
stevenmc: And I know there can be some of that like imposter syndrome, right, of like oh like people don't want to spend time with me. But that just simply isn't the the case, as I think you've witnessed. I know I've witnessed personally.
stevenmc: and I'm going to continue to hammer that, even if it's every episode, like if like hammer hammer that piece of it. oh So open up your practice. You know, that's all quite a bit of success.
stevenmc: But what I want to transition to is why behind breakthrough, right?
Chad Madden: Yeah.
stevenmc: Like what what what was that spark or what did you see that made you like this needs to exist in in the world?
Chad Madden: Yeah. So long term trend. Uh, at least when I opened in 2003, much of physical therapy in the country was driven by physician referral, right? So if you had physicians referring to you, that was the lifeblood of your practice. And in the very beginning, I operated under the same premise, which we all fall under, which was really from the 1800s, oddly enough, but it's, if I provide high quality of care, I'm going to get word of mouth referral. And basically every other practice problem is going to go away and never be an issue.
Chad Madden: That's not real, right? The AMA figured that it wasn't real in 1902 when they wrote it out of their guidelines, but that that thought process still exists today.
stevenmc: Oh, yeah.
Chad Madden: So I got very good at physician referrals, great at lunches, great at communication, and we we made a lot of headway there, like going above and beyond, literally five -star experience with physician communication.
Chad Madden: In 2008, that started to go away.
stevenmc: Yep.
Chad Madden: And I kind of had it in my head early that I wanted to help other the Ben Franklin model of what he did in printing, and that I wanted to mentor um or have like an apprenticeship for other private practice owners, that we were just going to have one or two clinics. We were going to run them very well. That's all we were going to ever have. And then um from there, we were going to help other practices. And I can remember early, this is kind of crazy,
Chad Madden: you'll You'll get a laugh out of this, but ah we had a receptionist and our total staff was four and I was one of those four. So it was me, a PTA and a scheduling receptionist, billing receptionist. Her name was Patty. And I said, you know, my dream is one day we're just going to have these one or two clinics and we're going to have people, practice owners flying in from all over the country to our clinic here in Harrisburg to learn how we do what we do. And she said, honey, that's very, that's very nice.
stevenmc: Yep.
Chad Madden: that's never going to happen. So Patty didn't last with us very long, but um it did came to fruition and we were able to do quite a bit. And yeah, so how breakthrough came to be 2009 to 2011, 2012 was pretty rough because in our area here in central Pennsylvania, the three hospital systems just started gobbling up the family physicians.
Chad Madden: So today, 90 % plus of those physicians work for one of two or three hospital systems, healthcare systems, and they're not, literally not allowed to refer out. They get scolded by the police and I've seen emails and, you know, I have friends there, our kids play T -ball together and we can hang out at picnics and, you know, everything else, but we, and we're on like a texting relationship.
stevenmc: yep
Chad Madden: I'll see the like their VIPs, but they can't send patients and masks to us. So that started happening. We had to replace the marketing. um I had figured out a lot with physicians, had figured out a lot offline, was trying to figure out online, um had done a couple goofy things like started posting YouTube videos for patients.
Chad Madden: Some of them went viral. Some of them are still running. I mean, we were up over 25 million views on YouTube videos that I made in 2010. So kind of.
stevenmc: that's awesome but
Chad Madden: But, uh, yeah, so stumbled backwards into a few things as technology was changing with how we could communicate and educate patients. Um, having said that in November of 2012, I received the cold email.
Chad Madden: Uh, it was unbranded. It was from Carl Mattiola, who's now the CEO and the co -founder here at Breakthrough.
stevenmc: Oh that's awesome.
Chad Madden: And, uh, it was for a five minute call. And again, completely unbranded, just was like, Hey, I'm researching private practice PT. Would you be willing to hop on a 10 -minute call with me um so I can ask you some questions? i At first, I didn't respond. Eventually, I did. I hop on this call. And in the first five minutes, I was like, wow, like this is way different. These questions that you're asking me, nobody's ever asked me questions like this before. What are you selling? And he said, I'm not selling anything. And and I said, OK, but you're about to. like
Chad Madden: Tell me what's coming." And he was like, I don't know. He said, i I'm doing research. And I said, well, what do what do you do? Like, why are you going through this process? And he said, I'm actually taking a course.
Chad Madden: He said, I'm the head of online sales at Tesla Motors. And so he had been and hired by Elon Musk to sell EVs online. with the It was basically one click shopping, just like Amazon.
stevenmc: yeah
Chad Madden: and And he figured that you can go online and read about them. And he said, I had a life changing experience in physical therapy. Back when I was in college playing football, he was a linebacker at LaSalle, had a shoulder injury, PT saved them from surgery.
Chad Madden: He was able to get back and play. And he said, I want to bring my skill set, my software building skill set to PT. Tell me what you're trying to figure out. So I would not admit a pain point to him, right?
Chad Madden: That I like i wouldn't talk about my pain, that I couldn't market or anything like that.
stevenmc: Yeah.
Chad Madden: But he said, what do you want to do? And I said, well, I figured out a few things in offline marketing. direct to the consumer. And I would love to be able to share that. So that's how breakthrough that was the very genesis, the origin story of how it started. And then what happened is Carl went on to develop a software called Clinic Metrics, which still exists. And ah he was sending me owners that he was talking with. I was owner number 17 that he had talked. He ended up talking with over 300 donors and he would make a personal introduction any time an owner was having
Chad Madden: an issue with physician referrals and wanted to go direct to consumer. So eventually, I was, I'll just keep rolling with this, Steven, if you're all right.
stevenmc: yeah please
Chad Madden: Stop me at any time. But ah he was like, you know, you and I said, listen, I hate working with practice owners.
stevenmc: no
Chad Madden: This is like, I'm trying to solve these odd problems. And I remember like this one owner was like calling me during my son's tee ball game. And it was, um you know, $500 ,000 in debt, and I'm going to be I'm going to have to you know foreclose on my house and declare personal.
stevenmc: Yeah, please.
Chad Madden: but And it was like this huge story. And my wife was like said, give me the phone. She took the phone from me. And she said, he will call you back later. And I was doing like all this for free. right so like and So I had this heart to heart with Carl.
Chad Madden: We sat down and I was like, listen, man, I don't really want to do this. like i And he said, you do. He said, you just don't know how to do it. so he and I'll bring this full circle for you, but, um, he, he said, listen, you just need to learn how to teach. And, uh, and I was like, okay, how do I do that? And he recommended this course. I woke up at a 3 .50 AM for 21 days in a row and did this course for three hours every morning. And I was really torn. Um, we had our two clinics up and running at that point.
Chad Madden: And I was filling them up and I was very complacent in my life and just happy. And then ah I went to game six of the NBA finals in 2014, where Ray Allen hit the shot. I'm actually in the picture. I'm right here. I'm in this panel, but ah on the way home, I had another mentor.
Chad Madden: That mentor was is Ernie Davis. He's still living. He's 93 years old now, and um and we get together for lunch once a month, and we've done so for 24 years. and Ernie was the first black salesmen insurance salesman in the country to write a million dollars in insurance.
Chad Madden: And he did it within his first nine months of his first job in like 1960s at the height of the civil war or civil war.
stevenmc: Holy.
Chad Madden: Sorry about that. um ah Civil rights movement.
stevenmc: Yep.
Chad Madden: And um so so he was in in Forbes and Ebony and a whole bunch of other magazines. And he just happened to be one of the first people I ever met as a physical therapist.
Chad Madden: And that was somebody else that was just a very lucky meeting. We were at this game together. We're flying home. And so he's 83, like a lot of gravity in his voice. And he was like, hey, what are you going to do with your, like, I know you're, he you just know him as Carl, but you're talking with Carl, you're teaching these owners. Like, what do you want to do? And I said, you know, man, sometimes I just think about selling everything and just doing nothing but commercial real estate.
Chad Madden: I have like four if feed to commercial real estate, I can just live on that income.
stevenmc: yeah
Chad Madden: And he grabbed me like under my arm on the plane and he like pulled me really close and he said, and that would be a shame. And I was like, got it.
stevenmc: Hi.
Chad Madden: Understand the message. So immediately after that, ended up doing that course that Carl had recommended, followed through, learned how to teach direct to consumer marketing, learn how to embrace, I mean, I'm very,
Chad Madden: dinosaur -like, um but you know embrace technology, especially with direct -to -consumer marketing, and start figuring this out. So yeah, that's a long -winded answer to exactly how I got here and the why behind it.
stevenmc: i I think there's so much there, right? I think from, uh, the, the great mentors to it not being a like direct path, right? Like obviously it had its own wines and in terms. Uh, and so I think there's multiple lessons to be gathered just from your story, just even as we've talked about it and really less than like 15 minutes, um, is that the, the path is not going to be straight and expecting that is kind of lunacy, right? Um, that.
stevenmc: you're going to have days where, yeah, like I, when you said, like, I want to give it all up and sell commercial real estate, like, man, yeah, there are some days when I just want to be like, you know what, I'm done. I just want to, I don't know, coach weightlifting athletes. That's it. Like, uh, and there's going to be those days, um, and, and hours and, you know, whatever the, the amount of time is. And and so, you know, getting ready for that, uh, it's not a straight path.
stevenmc: You do have to put yourself out there and and get a little bit of luck, right? and that Yeah, but luck typically happens to folks who continue to work hard and put themselves in positions to succeed. And then the last is, I think yeah you you mentioned the the videos from 2010 that and now have 25 million views, right? And it makes me think of the old, ah the the old adage of when's the best time to plant a tree 20 years ago? When's the next best time today?
Chad Madden: Here you go.
stevenmc: Right. Um, and so for, for those that are even thinking of going on ah an innovation journey, like what could look small and inconsequential and overall, like not hugely impactful today. Like time has an amazing thing called a, you know, compounding interest and and it can really, can really grow from there. I, I do want to to talk about, you know, your,
stevenmc: the direct to consumer marketing piece, right? And so you you saw this had what was probably, you saw it more real than anyone else did. And everyone else probably saw like a specter somewhere, right? Like, no, this whole position referral thing, like, we can't be tied to this, or else bad, bad things are going to happen to to our our our profession.
stevenmc: oh and And so walk me through maybe some of the things that if there's anything you can't share, I totally understand. But maybe some of the things that like you tested in a we call it brute forcing whenever you do something like manually and it's painful Like what did you brute force test early on and then you'll slowly or even quickly turn it into more of like a tech -enabled ah You know process
Chad Madden: Yeah, so as physician referrals were going away and it started, it it was very innocent in the beginning. It was like, oh, you're just not allowed to drop off your script pads anymore. Oh, you can't bring us lunch anymore. And then eventually we just get completely squeezed out. So the quick thought, there are five ways that we can get new patients in private practice. The lowest hanging fruit is reactivations. That's our patient list.
stevenmc: Yeah.
Chad Madden: So for years, I had been, um talking this is brute force. I forgot about this, but we, in the very beginning, I had a small desktop printer that was probably like 400 bucks and devastating for me to spend that $400 when I was starting out.
stevenmc: Oh
Chad Madden: And and and so 400 bucks, I did over a million copies on that printer.
stevenmc: yeah.
Chad Madden: It is not designed to do that, um but every month, We had a growing patient list and I would send out, and I remember I would do this on like some sort of Microsoft Outlook, design it myself, write the whole thing every single month and we would send it out.
Chad Madden: And I had no idea what to put in it. Right. I was just clueless and I was thinking, but I still send something out. So I would introduce staff or highlight a patient, a patient win with their permission, of course.
stevenmc: Yep.
Chad Madden: And we had a little misspelled word contest in there and stuff like that. but And we would print it on this hideous green paper that ah it was the cheapest paper I could buy at like office max or staples or whatever it was. And I just bought 10 ,000 sheets of this. So we would print them out. And then my grandmother.
Chad Madden: uh, who passed away in 2009, my mom's mom, and then also my aunt Helen who is still living. They would come in, uh, they would sit in the back. We would had this little folding table and they would just be loudly gossiping the whole time and they would sit and fold all of these letters.
Chad Madden: And we would mail them out. And it was like with a stick on postage stamp. And like, I mean, this is crazy, right? um But, you know, in the beginning it was a couple hundred letters. And then over time now it's we're up to, you know, 30 ,000 of those every single month. And obviously we work with an outside company to fulfill that. But in the beginning it was that. And what was crazy, I did not understand direct response marketing yet. um But I knew that when we sent something out, we had a lot of reactivations coming back in.
Chad Madden: and we would get more word of mouth referrals. So I understood that concept early. So that was offline. Online, we started with, I think this company's now defunct, but ah one social media, there was a gentleman named Joe Soto, who somehow I got connected with out of the Midwest.
Chad Madden: And and this idea was ah like e -magazines, I think they were called e -zines. So this is like early email marketing, like 2008, 2009.
stevenmc: yeah
Chad Madden: And we started doing some of that. And the idea was the fantasy is that, well, email is free and it's going to replace this gargantuan effort of time and money that we're doing with direct mail.
Chad Madden: And we quickly saw that it it wasn't going to replace it. Like it, you know, a direct mail piece, we we needed like a two to four week timeline in order to be able to send that out.
stevenmc: Yeah.
Chad Madden: an email we could change very quickly, like I could change it within a minute, but um it it just wasn't going to have the same sort of response. um So I was fairly quickly with Adderall.
stevenmc: Do you, do you mind if we stop right there actually? I love, so yeah I think people get into this analysis paralysis where they think they have to measure everything and like have all the answers, right? you The way that you're talking about this makes me feel like you just, you knew in your gut, like, Hey, this is working. This is working better than this. Like maybe even taught me if you can, you know, remember back to like even some of those, like give the conversation, how it played out in your head.
Chad Madden: Yeah. So, well, that you know, there's a, there's some cliche where you reorder the ready aim fire to like fire aim. But that's pretty, I mean, most of my professional career early on was backing myself into a corner and then figuring out how to work out of it.
stevenmc: but
Chad Madden: So, right. Like its it's, we, most of us have a jaded experience and then we open up and then all of a sudden I discover, I have no idea how to market. it at my services.
Chad Madden: I have no idea how to hire people. I have no idea how to, you know, that billing or technology was even if I thought, you know, people just scheduled at the computer and that's all there was to it.
Chad Madden: There's a lot more than that. So um getting back to your question, you want it like a specific instance?
stevenmc: Just even how you like thought through it, like, you know, as you were sending out the monthly letter, right? And were you tracking the, so you were tracking the reactivations or were you just like gut feel, it feels like I've seen more people that I know come back in. I kind of, what was that? that Or a bit of both.
Chad Madden: Yeah, I had a very generic dashboard that I kept by hand. So I, I kept metrics by hand in the beginning. And I would, every day I would write down four vitals, new patients, visits, ah it attendance rate for that day and total cash collected. And I would, then I would tally up weeks.
Chad Madden: And, and like, I never missed. So it was like, by the time I went home every single day, I had those four things written down. And then I would, again, this is by hand, like in an Excel spreadsheet in the beginning. And I mean, now we just print out a report in five seconds, the EMR, but, uh, so I would tally that.
stevenmc: yeah
Chad Madden: And then weeks become months, months becomes quarters, quarters become years.
stevenmc: Yeah.
Chad Madden: So I knew that whenever I sent out that patient newsletter, there would be an influx of new patients. I was not discerning amongst five different new patient channels.
stevenmc: Yeah, yeah.
Chad Madden: But I knew total new patients would go up every time I would have this effort. And I could see the same thing happen in email, but not at that time, not quite as powerful as direct mail. And again, this is early 2000s.
stevenmc: Yeah, I just think that's so valuable for people to hear that they don't have to have all the analytics set up prior, right? Just track the thing in Excel. I mean, there we still do a heck of a lot on that front. and like For example, for for conferences on our side, I have a pretty good idea of how many new clients that we're going to to convert or to to grab at a breakthrough event. like It's like, all right, it's about three to five per event, and like here's how it looks.
stevenmc: you know, just can can make the ah ROI case in my head. and i I don't need to think about it any further. I just, so many people that I talk to are think they have to have the the plane fully built before they he fly it. It's like, no, not at all. But I'm sorry to interrupt. So you you looked at, so you saw, okay, email was not gonna replace the direct mail, right? And so then what what what happened next as you started to go through that?
Chad Madden: Yeah. So then we, um, after that, we wanted to figure out a way to market direct to the consumer. So I tested, uh, some very expensive, poor working print ads in the beginning, uh, banner ads were a thing.
Chad Madden: I don't know if you remember that even they were gross.
stevenmc: oh yeah oh yeah
Chad Madden: Uh, it was, and everybody was selling space on their website. And, uh, yeah, so wasted a lot of money doing that. And, really trying to figure out. something So in the very beginning, the most common thing that I saw other clinicians doing was advertising like a free screen.
Chad Madden: Everybody's doing it though. Right. So there was no real benefit there. And then what I learned is the more that I studied marketing and got into that was there are really three things that we can offer in marketing.
stevenmc: Oh yeah, oh yeah.
Chad Madden: We can off. And by the way, I always, like most other clinicians, I always blamed the media type that I had selected. So if it was a print ad, I would never blame it on me. I would always blame it on, well, that newspaper doesn't work.
stevenmc: yeah
Chad Madden: Like they're, they're, they must have no.
stevenmc: my messaging is perfect
Chad Madden: so Yeah. Yeah. Nobody ever thinks about the messaging and we can talk about that a lot, but, uh, so in the very beginning with like a print ad or radio or TV or whatever I was advertising on our banner ad, we were all always offering free screens.
Chad Madden: And then one once I learned that you can really offer three different things, you can offer a free product or service, right? Or you can offer education, right? So there are the three things you can offer.
Chad Madden: And then when we tested education, which in our case was the way I had been doing workshops since 2000, like my first year as a PT.
stevenmc: yeah
Chad Madden: um um This is a crazy story, but I'm actually really good friends with, he was 16 years old at the time, somebody who came to my first workshop ever. And we're he's now 42 years old or something like that, with a 16 -year -old of his own, but ah kind of crazy.
Chad Madden: But um yeah, so had been doing workshops for a while. We started promoting them with print. And it that went really well.
stevenmc: Yeah. Yeah.
Chad Madden: And I got that from, I heard another owner talking about doing newspaper inserts on golden and broad insert um and doing testimonials. It was a dentist from, I think, Missouri that I had heard that.
Chad Madden: And then I i was like, oh, I wonder if we could promote the workshop and we did it and we had like 96 people register for a workshop. And I was like, holy cow, this is crazy.
stevenmc: ah
Chad Madden: So we did that. Eventually that media died. And what we were forced to do is people were getting their news online. And then we had 2009, 2010, 11, we had to start converting over to advertising online to figure out how to do that.
Chad Madden: I wasted over a hundred thousand dollars in figuring that out.
stevenmc: Cool.
Chad Madden: When I met Carl, he was like, hey, what are you trying to figure out with your marketing? And I was like, well, i'm I'm doing this offline really, really well, trying to figure out how to do it online. And he was like, just give it to me. And so he ran one weekend or one week he ran ads for our next workshop and like 37 people showed up. And I was like, all right, like I don't have the skillset to figure out this out. i So if you can just help me do this from here on out and yeah, that's,
Chad Madden: the So over the years as media comes and goes, we have to be flexible and adjust, but it starts with, I think you called it brute force in the very beginning.
stevenmc: Yep.
Chad Madden: And then and over time we get more and more viable and streamlined, uh, eventually, but, uh, yeah, it's a, it's a process that we have to go through and almost any system within the practice.
stevenmc: Absolutely. I would imagine that you as an owner, I don't even mean that in the broad sense of the businesses you've owned is, you know, you look out and you probably see a hundred, maybe a thousand fires that need to be put out, right?
Chad Madden: Yeah.
stevenmc: It's like, which one do you go choose? Uh, and that, that whole decision making process I think is, is key. And, you know, I think another piece that I'm picking up here too, that I think it's worth highlighting is you can go it alone, but it sure does help if you surround yourself and bring in, you know, whether you call them a teammate, a co -founder, an employee, like whoever it is, like surround yourself with.
stevenmc: folks of the the same or preferably a better caliber, like I know my team is is way higher caliber than I am. Thank goodness. And that just, it's not a one plus one equals two when you start adding in those types of of talents.
Chad Madden: in.
Chad Madden: Exactly right. Yeah. Everything that I'm talking about here is really a we, uh, I wasn't alone in the journey.
stevenmc: Yeah.
Chad Madden: One of the biggest turning points is exactly what you're talking about. Uh, for me, Steven, which was early on, I was like, you know, what, what does this look like if I'm not our best clinician? And maybe I should just hire clinicians who are way better than me.
Chad Madden: I'll give an example. We had a, at our last event, there was a ah runner who came through
stevenmc: Yeah.
Chad Madden: and ran on the treadmill. um I had requested the family get an MRI just based on what I had seen. And I i can't read an um MRI well.
Chad Madden: I mean, I took courses in it, but ah we have Mike Finkel and staff who teach nationally.
stevenmc: Yeah.
Chad Madden: um We threw him in the DVD. He scrolled through, immediate like immediately saw the injury, was like, hey, look at this. This muscle's on Slack. Looks like an avulsion fracture.
Chad Madden: Just went through the whole thing, and it took two minutes. And you know, it's the point that you're bringing up with mentors. um And I have a pretty strong point for you on that.
stevenmc: Please.
Chad Madden: But the
Chad Madden: I was with an owner yesterday who was looking at me talking about rep per visit, which is probably the biggest pain point in all the physical therapy right now is we're just, you know, we have this tremendous downward pressure on reimbursements and everything else. And we can talk about statistics till we're blue in the face, but it's not going well for us. It's not headed in the right direction nationally. And this owner was like, it was a husband and wife. We were on a call and she said,
Chad Madden: everything that is in the system that you're using in your practice, won't we just figure that out eventually? And I said, well, how long have you been in practice? And let's say it was 10 years.
Chad Madden: And I said, how's that going? Like, do you have an abundance of time to test a whole bunch of things? Or would you just rather learn from people that have done it already? And it's, you know, now with breakthrough, it's not just me, it's thousands of other owners that have implemented the processes and are in, you know, in
stevenmc: Yeah.
Chad Madden: In Arizona, they do it a little bit different than Texas. And they do it a little bit different than Pennsylvania and you Florida and New York and every other state. There's all these little adjustments and colloquialisms and adaptations that people have. um But I said, hey, if you have a ton of time for testing and you have time freedom go galore, first of all, that's very rare in private practice right now. But if you have it,
Chad Madden: go nuts.
stevenmc: yeah
Chad Madden: And yeah, and that that was the end of the conversation um the in a very positive way.
stevenmc: exactly
Chad Madden: And um the other thing that I want to say on mentorship is, I mean, I've been blessed with three amazing mentors.
stevenmc: yeah
Chad Madden: And I did something by accident in the beginning. um One of the earliest dinners that I ever had was a gentleman.
Chad Madden: He was a commercial real estate owner that I had leased from in the very beginning.
stevenmc: Yeah. Yeah.
Chad Madden: And he went from zero to $500 million dollars portfolio in about 25 years. Absolutely amazing.
stevenmc: Yeah.
Chad Madden: And he had four Ivy league degrees from three Ivy league schools, Penn, Wharton and Harvard. And it was an intimidating first meeting and he ended up spending about three hours with me. And um when I got home that night, i like my I was just overwhelmed. And I wrote down every single point that I could remember. And I and including this very obscure reference from a Harvard Business Review in like 1967. And I went up and found the actual quote that he had. And I said,
Chad Madden: Uh, and I wrote him an email the next day. I said, Norm, I said, here are my notes from last night. And it was two pages of notes. And I said, I just want to make sure that I understood you. Correct. That would the second I did that, it was instant.
Chad Madden: Like lifetime.
stevenmc: Yep.
Chad Madden: Right. instant like credibility for the rest of my life. And I've asked him some very not intelligent questions through the years, but the second that I did that, it was like, okay, I value your experience. I respect everything that you've done in the marketplace. Please show me. And then anytime that I was in a bind, as I was buying and selling commercial real estate, he was always there to support me. He's completely retired now and I still reach out to him you know once a year and he always has a very
Chad Madden: amazing answer um for me because of what I did 20, 21 years ago, right?
stevenmc: But it's such a great practice, right?
Chad Madden: Yeah.
stevenmc: And ah I'm reading or i guess listening, as as is my typical mode, to the speed of trust by Stephen Covey, a junior, I believe, not the the senior.
Chad Madden: yeah
stevenmc: And yeah, it's it's all about you how how do you get to trust, right? Do you believe someone? And do they have the the character?
stevenmc: Do they have the competence, right? and so I think part of that that confidence piece in showing it, which is entirely in your power, right, is to do exactly that, right? Send the handwritten thank you note to follow up and just show that you actually listened, right? And that's such sage advice. And I could just, plus one, plus one, plus one. Like, absolutely. That is, I've seen that in in my career.
stevenmc: And even like personally, like some of my my best friends were created from just like, oh, like you want to do that? OK, let's go do it. I think of a really close friend of mine. His name's Andrew Deloge. And we met an undergrad. And long story short, my dad owned some oil leases and used a heating element that his family company produces called Watlow. And he you know we we met.
stevenmc: And we got just talking and was like, oh, I'd love to see that. Like, okay. And then three weeks later, we're driving from Manhattan, Kansas down into, uh, to near Iola and actually did it. And I think there was, like, that is a definitely a non, call it like non -career professional story. But I think it shows like, if you just follow up, show up and be there, you're going to be surprised at how much you're going to make yourself stand out from the the rest of the group. It's just.
stevenmc: respond to the emails, like just the the simple basic stuff. um But I really appreciate you giving that anecdote for how you created that lifelong mentor with something that probably even helped you, right? Like I love writing those because like, okay, like here's all my takeaways and now I'm not going to forget them after I go to sleep tonight, right? and Have like osmosis into the pillow and it all falls out. So I i thank you very much for that.
stevenmc: we you You mentioned on that call the the two owners, revenue per visit, right? and And you're right, it's it's it's going down. And I will stand here and say that remote therapeutic monitoring is not the silver bullet to it. It's it's not gonna be helpful, absolutely, but five to six bucks revenue per visit is is going to to help, but it's not gonna change the world.
stevenmc: right, and we're very open and just like, yeah, this is it is what it is. And so, you know, we'd love, not maybe not so much the statistics side of it, right, but as you look at the declining revenue per visit, how, what brings you optimism, and and where do you see there there being opportunities?
Chad Madden: Yeah, great question. um And this is probably the thing that i've the one area that I've spent the most time on in the past year, especially with practices that are ah mitigating the revenue per visit decline. So having said that, there there are four big areas where I see owners winning. um The first one is what What is the biggest leak in terms of profitability in any private practice? Typically, the most common one is underutilized schedule time. So I've hired a therapist, they're not busy. um And the second one is underutilized um space. So every month we're paying those expenses, employment expense and space expense, which is rent your you know your rental um or lease or whatever you have, utilities, et cetera.
Chad Madden: um But if they're not filled, if that's not full or near capacity, we're losing a lot of money.
stevenmc: yeah
Chad Madden: Flushing money, ah it's unreal. So that's one area where if a practice has, let's say, 3 ,000 square feet and they only have two clinicians and they could really house six, the game is let's get to six as quickly as possible, right?
stevenmc: Yup.
stevenmc: Yup.
Chad Madden: So that's number one. Number two is...
stevenmc: Can we stay on that for a second, actually? Because even when you talked about your dashboard that you created when you were first starting out, ah you you didn't you didn't say cancellation rate, you didn't say arrival rate, right?
Chad Madden: Yeah.
stevenmc: you looked at how many visits there were that that day, and I was just talking to another owner yesterday, and and she she's not a PT by by background, and and that's how she thinks about it.
stevenmc: She's like, if I can refill a cancellation, I'm not gonna ding anybody for it. In fact, if anything, I'm gonna keep praises on my front desk for getting that that' that spot filled.
Chad Madden: Yeah.
stevenmc: So maybe, how do you feel about Like that conversation, right? Are you like a cancellation rate or is it just visits per day? Like how how do you, how do you think about that?
Chad Madden: Yeah, we we call it attendance rate.
stevenmc: So good.
Chad Madden: yeah I mean, our standard is 92%.
stevenmc: Good.
Chad Madden: And we in our situation, we're looking at quite a few clinicians. And we we know that any time a clinician drops off, a cliff with a tenants rate, they're likely dropping something out on the very first visit in terms of patient education.
stevenmc: Hmm.
Chad Madden: So yeah, we look at that. And yeah, we have names for syndromes for the clinicians that that's happening to, but we'll we'll ah we'll skip over that part.
stevenmc: ah
stevenmc: So there's the first two, clinician time, space, and then yeah, go ahead.
Chad Madden: Yeah, so that we call marketing for profit. which is like that bucket. The second bucket is lifetime patient value, which is where RTM comes in, right? So is there something that we're already doing that we're not really billing for, charging for? So that is, you know, Sarah Health, the RTM. So can we, is there a way that we can get reimbursed? Are we leaving money on the table by not charging for something we're really doing anyhow? um Is there a cash -based service that we should be adding? That's a huge one.
stevenmc: Yeah.
Chad Madden: um Is there anything else that we should be doing around serving the person who's coming through with other treatment technologies or other services to help them get a better outcome? That's the second bucket. Third bucket is insurance relation. This is quick and easy. You can attract more of your best payers, you can attract less or drop your lowest payers, and you can renegotiate rates. And then the fourth big bucket is what I would call practice math, right? Like, you know, so if, let's say we had two hour appointment slots and our 90 % of our insurance companies that we participate with are going to max out the reimbursements at four units. In that hypothetical example, you can see we're giving away a lot of care. So we need to, so scheduling on the hour would be better than scheduling on the two hour, right?
Chad Madden: So we have to be willing to look at that based on our own payer mix and based on the insurance contracts that we have in place while we're making sure that we're being compliant and ethical and everything else that we need to do by responsibility to the patient. But those four big buckets are really how we can mitigate um declining revenue per visit over time and we see owners being very successful with this.
Chad Madden: I mean, we've had owners that have increased that you know just by paying attention to those four buckets, 20 % increase within a year, so which is a pretty big deal.
stevenmc: That's awesome.
Chad Madden: Yeah.
stevenmc: I mean, as a patient that wants to see this ah wants to c PT not only survive, but thrive, like the idea that physical therapy could not exist as as I hit that Medicare age is, there's not a word for it.
Chad Madden: Yeah.
stevenmc: It's beyond terrifying. Like the idea of losing my movement and then everything else goes from there. It's like, as soon as I can't move, I'm i'm done and I know that. um And so when I hear stories and it almost like averages, like, yeah, we're helping boost by profit by 20%. Thank you. Right. As, as from, from myself as a patient who wants to be able to be seen in the future and be treated and be cared for and be taken to a hundred, to 110, 115 % of where I was. you Thank you.
Chad Madden: yep Yeah, there's a margin of safety that we it's there's a game we must play. And if we're not willing to play it, we go out of practice and we limit you know accessibility to care, which is a very, it's a very real problem. I i talked with two owners last week who both closed their practices. One last day was Friday after, I think it was 44 years in practice.
Chad Madden: absolutely brutal to go through. So the your original question was what can we do about revenue per visit? They're the four big buckets. And if owners, you know, if we're talking with an owner and they're not willing to start paying attention to that, we know there's a high likelihood that they're less than 10 % margin and they're a speed bump away from having to close their doors forever. And that is brutal because we have such a value, you know, in terms of dollar per outcome,
Chad Madden: I would put physical therapy up against any other profession and really the family of conservative care, which includes PT, chiropractic care, podiatry, dentistry, et cetera. I would put up our outcomes against anything else in medicine or healthcare care right now, because there are a lot of expensive procedures that that don't have the the same results that in terms of positive outcomes. And yeah, I mean, we need to fight for that. And it's really right now with that all the pressure that is within the industry,
Chad Madden: It's really an opportunity for those that want to learn how to do it to to fight for their and their practice and keep their doors open because it's a huge marketplace advantage right now.
stevenmc: Absolutely. I just, you hit the nail on the head and that is on physical therapy, having like such high ROI when you think of the dollars put into the outcomes that that come out. And in my opinion, that is not research backed, you know, granted is physical therapy in particular is not just movement health.
stevenmc: is you have behavioral change specialists that can do more than just get you feeling better, right? It can truly give you, like so many times you come out with a better tool, a better habit, something else that that causes a behavioral change in a patient's life. And yeah, you're right, like Eli Lilly can't ah manufacture that and they can't put it through for for patent, so if at least not yet. Maybe there's a peptide out there that can do that. We'll see. um I doubt it. Also, I'm not taking it. the But yeah, I completely agree with with all those points. And while we're, while at least at Sara Health today, it our core focus is around facilitating the RTM reimbursement to increase that revenue per visit.
stevenmc: We are seeing drops in cancellation rates and other, you know, called auxiliary benefits. And I i don't know exactly what the business will look like in 5, 10, 15 years, but I, you know, it's kind of funny how you mentioned at the very start that you you told, was it Patricia?
stevenmc: What was her name? Patty?
Chad Madden: Yeah.
stevenmc: Yeah, Patty. like you know I think, Yeah, I think we're going to have people flying in here like I did a few weeks ago ah to Harrisburg to check out what we're doing. And you know, I've gotten laughed at a couple times for for this, which means I think that means I'm on the right path, which is I'm going to figure out how to grab more dollars into PT from areas that no one else is looking at today, right? Like why in the world is signify health
stevenmc: paying a nurse practitioner somewhere around $150 to do a health risk assessment in someone's house when they're getting physical therapy and a DPT could absolutely do it. Like what why, right? And why are there this massive groups of startups that are grabbing HEDIS measures and helping with HCAHPS, like all these other things when the relationship and the data exchange and the PT visit like goes far beyond.
stevenmc: any of the things that you can collect outside of this. So i I think there's something special about the relationship that gets made between a PT and a patient. And you're obviously figuring out ways to use that today, right? Like reactivation, referrals, references to other patients. And and not that it's all about monetizing it, right? But like you're you're in a battle, right? So you got to use what you have available to you. And so, you know, Chad, I love I've really enjoyed the you know two, almost two and a half years, I guess it'll be three here pretty soon, that that we've gotten to to know each other. And I just very much appreciate what you're doing it and helping to drive the the industry forward. We're going to end on one last question, which is, if you had a magic wand and you got to fix one thing within PT, what would it be? And no,
stevenmc: You can't ask for more wishes. I'll go ahead and get in front of that. But if you had a ah magic wand and it could fix one thing, what what would it be?
Chad Madden: Yeah, um it's the same problem, but I think there are two ways to solve it. So I would want one of these. The first one is the cost of education today for a DPT is absolutely insane. So um when I graduated in 2000 from College Misericordia, up 1 -0 in the College World Series right now, so go Cougars.
Chad Madden: um they
Chad Madden: The maximum I was allowed to borrow for my master's of science and physical therapy degree was $24 ,000. So I graduated with 24 K total. We are seeing students come through now that are at 300 K and that's in debt.
stevenmc: yep
Chad Madden: So now they have a mortgage payment for the next 30 years, right? I was able to retire my student debt in a few years, like very quick and easy. My first job, $41 ,000, right?
Chad Madden: So almost doubled my total student debt. Today, you know, your entry level DPT is coming out at 75K with 300.
stevenmc: Yep.
Chad Madden: So we want like 10X the wrong way.
stevenmc: Yep.
Chad Madden: So magic wand, I would use it on that, solve that problem. Or the other one is be more valuable in the marketplace. If we look at the conversion factor for Medicare alone,
Chad Madden: When I was volunteering, when I first volunteered in a PT clinic 1994, compared to today, the reimbursement rates on the conversion factor for Medicare is lower today than it was 30 years ago. And that's no adjustment for inflation. So if you add in inflation, it's or we're worth less than half of what we were 30 years ago um for a single visit, which is also insane. So if you you have to decouple one of those. It's either the cost of education or we're getting reimbursed more by insurance companies for the services that we're providing.
Chad Madden: I'll take either one, Jeannie. So additionally of we can go either way.
stevenmc: Oh, oh that's... Man, I... If I had to pick, off the cuff,
stevenmc: I think I would go education. I think I would go education, as you know, with working with many practice owners. There are a lot of practice owners who are business owners by accident and not the best at extracting value.
stevenmc: And didn't get into it for that. And so I think if, but i I don't want that to get, I don't want that to get lost along the way. Right. And so I think there's some really amazing things that that altruistic attitude provides to patients. And so I think if I was to choose you know from your two wishes, I think I'm gonna go education because it's a, you're right, it's a mortgage payment for the rest of your life at a house that you'll never get to live in. That's, it's because it's I think it's PTs and veterinarians are the highest basically debt to income ratio in the US back and forth. Well, Chad,
stevenmc: Thank you so much. Please, if you want to tell your folks that somehow don't know you where to find you and all that, please do. But before we wrap up.
Chad Madden: Yeah, so very easy to find online. Breakthrough is very straightforward. It's getbreakthrough dot .com. um I am, if I'm allowed to say so, Stephen. I do host a course specifically around revenue per visit where we talk about adding RTM and those four, we call them the for -profit levers, which is really learning a system to scientifically go out your revenue per visit and improve it based on your unique practice. um That course is called profitability under pressure. We accept applications at getbreakthrough dot .com forward slash apply. And so if you're an owner and you're interested in that, you can go there, getbreakthrough .com forward slash apply and to apply for the next course.
stevenmc: Yeah, I believe, uh, pup, uh, is the the abbreviation, which I find that's that's great. Uh, so yeah, uh, don't go to get breakthrough slash pup, go obviously to to get breakthrough slash apply to do so. Um, but Chad, thank you so much. I really appreciate your time, your openness to discuss everything from.
stevenmc: You're volunteering at at the start through your your mentorship opportunities that you were able to make the most out of and some really tactical tips for folks to be able to, yeah I think, get at least a couple things from this and hopefully also for the the owners that are listening, some hope and optimism and even ah a route to go to be able to increase there their revenue per visit. and be able to treat patients, not just for the next year, but for the next decade and beyond.
Chad Madden: My pleasure, Steven.
stevenmc: Thank you.
