Transcript
Dave Kittle_ DPT: Thanks.
stevenmc: Hello, everybody. Welcome back to another episode of The Disruptors, where we're highlighting innovators within the physical therapy industry to help make innovation one IOTA more accessible. Today, I'm blessed to be joined by Dave Kittle. Dave, welcome, and if you could please tell the audience a little bit about yourself.
Dave Kittle_ DPT: Steven, good morning. Thank you so much for having me, and I'm a physical therapist, practice owner, always been an entrepreneur, and I own a mobile concierge practice in New York City called Concierge Pain Relief. We deliver on -demand physical therapy around New York City, and then also formed a small investment group, the field maker group, and we're looking to continue to speak to owners about either partnering or acquiring some or all of their practice, and that is pretty much me in a nutshell.
stevenmc: So that's you in a nutshell. And um ah well we'll peel back some layers to that onion over the course of the conversation. you know how How did you get into physical therapy? What's what's your why behind becoming a physical therapist?
Dave Kittle_ DPT: um happen to test well with the sciences in terms of picking a track and having you know the the traditional guidance counselor kind of help you with what type of ah career path might be good based on your test scores and your or my attributes and things like that always been a people person always been an athlete played ah soccer and baseball in high school, played ah division two baseball in Philadelphia. So always been an athlete, always had some aches and pains myself. And physical therapy is right at the intersection of dealing with people, dealing with you know injuries and aches and pains. And so it seemed to be a good fit.
stevenmc: you know You don't hear that soccer -baseball combination very often, but I'm right there with you, so ah maybe that's why we get along. It's one of those those rare folks that plays soccer and baseball versus soccer and something else, or football and baseball.
Dave Kittle_ DPT: oh ah yeah
stevenmc: um that's ah That's really cool. and So you you played at the collegiate level. ah yeah What was that experience like? did it did it Did it shape the way that you think about how you practiced today?
Dave Kittle_ DPT: I don't know if it changed or modified the way I practice today. um One thing that is interesting is that my conference the the conference in Philadelphia, in the Philadelphia area that we we're in, um the the CACC, the CAC the cat conference, for whatever reason, um my between my second and third year, it the conference changed from metal bats to wooden bats, which ah which doesn't make sense because the biggest D1 schools, that like Texas, Florida, you know just recently the College World Series, Texas A and &M, Tennessee, all these huge powerhouses, those guys get drafted and they still get to use metal bats, but we had to go to wood bats, which made no sense.
stevenmc: Yeah.
stevenmc: but Yeah.
Dave Kittle_ DPT: um so i think you know maybe adaptability because obviously you want to use a metal bat because obviously it's easier to get more hits and have the ball uh travel faster and further with a metal bat um and not not not even to brag but like i only hit two home runs in college and one happened to be with a metal bat and one happened to be with a wood bat and the baseball purists say if you can hit a home run with a wooden bat like it's it's a legit home run but the the lesson I suppose would be um you know with that adaptability so maybe it's kind of a thread in our conversation around you know medicare or insurance and physical therapy um because there's some forces that like
stevenmc: ye
Dave Kittle_ DPT: We don't really have full control over and you kind of have to adapt and and move forward based on however the current conditions are.
stevenmc: You know what's funny is when you said that, the first thing I thought of was commercial insurance. like
Dave Kittle_ DPT: before Before I even brought it up.
stevenmc: As soon as you said metal and wood bad, I was like, oh yeah, this is like playing with United. ah that's That's the very first thing I thought of. so It's funny that you also wrapped it around to the the insurance side. um and so so That's why you became a physical therapist. right and so yeah what's your why behind I know you've got two things going, right but let's start with the the mobile therapy practice. right like why why did you why we Why did you start it and and why do you what what keeps your passion alive for that that business?
Dave Kittle_ DPT: Sure. So why I started it was kind of happenstance or accident. I had worked for a couple of different other ah mobile practices back in 2014, fit fourteen no, 15, maybe 16, 17 in that area of time. And it was just like a you ah couple of different side hustles because I think I told you we we, by the way, we tried to record this and I had some tech issues with actually downloading and recording this episode.
stevenmc: Thank
Dave Kittle_ DPT: So that was my bad. And I think I mentioned in that episode, if I didn't, you and I probably talked about it.
stevenmc: you.
Dave Kittle_ DPT: But back in 2015, 2014, 15, 16, around that time period, I had a tech startup and it was called Venishal. It was secure HIPAA compliant messaging. It was an iOS and an Android app. And we were selling it like you are. We were selling it right to practice owners for a monthly membership. And it was you know patient experience and communication. They could text their therapist without the therapist giving up their cell phone numbers. The patient could they could message and text the front desk to change appointments. to The front desk could settle help them settle balances, whatever. Anyway.
Dave Kittle_ DPT: um I started doing home visits and working some other PRN, physical therapy jobs, just to pay the bills. So I got into the whole noble home visits, concierge -type style.
stevenmc: Yep.
Dave Kittle_ DPT: I got into that by happenstance, um so it wasn't even on purpose. and then Learned a bunch from a couple of different companies that I worked for and obviously I got to the point like most entrepreneurs where it's like You know if I'm only making you know I don't know 50 % of what I could be making like Why wouldn't I just like if I know the whole model if I know that if I understand the whole business? Like I said in the top of the show I've always been an entrepreneur and so I just went out on my own and ah started hiring therapists and started my own practice that way and
stevenmc: You know, I think there's a a key point there, right? Which entrepreneurship is is very often not sexy, right? um And, you know, you you mentioned paying or doing PRN to be able to pay the bills and and I get that. I mean, I have not been full time on Sarah for the seven years of our existence. You know, luckily I'm i'm blessed to be now and have been for a while, but it hasn't always been that way, right? Like it did involve saying no to a lot of things that my friends were doing and even family at times to be able to keep this thing alive um and now it's a you know a much more going concern which is which is helpful but like it could be years right before something actually takes off and and it it really starts to hit. So I appreciate you both talking about you know your tech startup experience as well as you're getting into like, hey,
stevenmc: it might suck, like, for an extended period of time. ah But that's, but I think if you go into it, that mindset, and just that, hey, this is probably gonna be really tough. If if you're married, ah you know, have a partner, whatever that is, like making sure that they're along for the ride, and you set expectations properly with them, I'll admit I did not do the best job of of that. And you know, that's a tax that that I have to pay from time to time now. But um I appreciate you being transparent on that part of your your journey, because I think it's important for people to hear that, yeah, you might have to cobble some things together. You might have to, you in my case, it was some site consulting, luckily, that it was able to to find, but even that's, like I'm sure even you working as PRN, right? like You gotta swallow your ego hard to do that.
stevenmc: um
Dave Kittle_ DPT: because Because at that point, you don't want to be doing the you don't want to be doing the side thing to pay the bills. Yes, 100%.
stevenmc: yeah Yeah, and then you got to go like, get a job, right? and Hey, yeah, like, I only want to do part time. well Why? Well, I'm working on this, this venture. Oh, how's it going? Like, well, obviously not great because I'm here.
Dave Kittle_ DPT: Right, right.
stevenmc: Oh, it's I can laugh at it now. But you know, there's tears on the inside. And so yeah, that's that's how you got to the mobile therapy. I like that just Yeah, you're like, hey, like I get this, right? and And now I've developed this expertise from doing it. And for the FieldMaker group, ah you what what's the the the why behind that?
Dave Kittle_ DPT: The why behind that is, I mean, there's ah there's multiple factors, but it's basically like, ah one of the concise things I can say is you and I have both started things from scratch. This is what I did say on the previous recording. I remember this now. You and I have started one, or we've started multiple things from scratch and and buying something, I'm not saying buying something is easier than starting something from scratch. I'm not saying that buying a physical therapy practice is easier than starting one from scratch. But um you can buy something and then it's easier to optimize it if you acquire something that's already been established. And typically, whether it's investors, banks, whatever, they'll look at something that
Dave Kittle_ DPT: has been in existence for 10 or 15 years, like a physical therapy business or any other business. And there's a lot less risk there. There's a lot more risk when I was doing Venetial. There's a lot more risk when you know with you doing Sarah Health. So um you're you're buying something that potentially has, it is potentially the risk is potentially mitigated, meaning a little bit lessened. It's not totally gone. um And from what I know with marketing and sales and the patient experience and reactivating patients and growing a practice. um And from my other two partners in the field maker group, Sturdy McKee and Marshall Sterman.
Dave Kittle_ DPT: I brought in some other expertise, so the idea is to acquire something and then we we know how to quickly optimize it and and potentially grow it even more, you know legally, compliantly, all that. um And in the thought process is growing that faster than we could just open up a de novo, was a startup clinic.
stevenmc: course
stevenmc: Absolutely. I mean, I just, I think of the rule of 72 with that, right? And so if you come into it saying, Hey, I think we're somewhere around like 15 to 20%, uh, you know, better than with the combined that we bring, like the combined knowledge and experience that we bring in 15 to 20 % better. We can grow it at 15 to 20 % more. Well, then you'll double basically three, three and a half years faster. Right. And so you you start to look at that math and like, Hmm, And I think like Alex Formozzi talks about this too.
stevenmc: He's like, it's so much easier to go from one to 10 million than it is from zero to one. Like it's just insanely easier.
Dave Kittle_ DPT: Thanks.
stevenmc: I'm seeing that on a, gosh, on a daily basis at at this point. It's like when the machine starts running, it's like, whoa, like this is this is kind of nice. and And it depends on your personality, right? like There's, I think of some of the, you know, this is more of the software developer persona side, but you you have your hackers that they are great and that get an MVP out, do that, and they do really, really well there. There are others that do terribly there, right? They're like, no, we need to have business requirements like process and and standards, you know, so on and so forth. and
stevenmc: It's just finding where you fit in that in that timeline, because there's an extreme value in the zero to one people and just doing it over and over and over and over again, there's an extreme value in your one to 10 people and extreme value in your 10 to 1000 people. Right. And so I think finding your fit there is is extremely important as you think about where you fit in the innovation landscape. But Dave, you've already given, I think like two very, you know, very good, very good points.
stevenmc: I think they're actually different than the first conversation. So, you know, they're kind of awesome. And that is adaptability, right?
Dave Kittle_ DPT: Yeah.
stevenmc: So, so being adaptable to to the environment. And, you know, I think of Ryan Holliday's book, right? The obstacle is the way. And so if you look at it as an obstacle, like, oh, I'm going to give up, like, Okay. But if you look at it like, oh, that's an obstacle, like the way must be through there. Um, it, you bring that adaptability, you can see a lot more success. And I think two for folks looking at, gosh, where should I, where should I innovate? Where should I put my time? Not only is there nothing wrong in looking at optimizing a process versus starting a new one, but like
stevenmc: might be a better place for you to get your feet wet, right? Like, hey, just make something a little bit better instead of trying to to completely reinvent the the wheel. um so i i like this I like this a lot. ah you Normally we don't get to this question as early, but knowing where it's going to go, I want to get it out early and have a a lot of discussion around it. And that's my favorite question. um If you had a magic wand and could fix one thing within PT, what would it be?
Dave Kittle_ DPT: Yes, I know you and I discussed this previously and I really think um this is something that is possible and potentially reasonable from all stakeholders from all sides of the table and hopefully doesn't even require a magic wand. It will, but I'm saying like actually implementing something like this, I'm not saying like I don't know, every physical therapy visit needs to be a million dollars. like ah that's That's facetious, that's just not gonna happen. But my answer would be ah site neutral payment. And I think I, so I i posted a video on my YouTube channel recently and it was basically saying like how to legally make $300 per visit for Medicare Part B instead of $100 per visit. And obviously it got a ton of views, it got a ton of ah comments. i got it I got a lot of feedback from different practice owners across the country.
Dave Kittle_ DPT: messaging me that cold they never messaged me before all that but at the end of the day it was what kind of our colleague Scott Gardner calls site neutral payment and I'm glad that he put he put some terms to it because I was I was just calling it like you know that private practices you know don't get paid they get paid you know a third of what these hospital contracts get paid and
stevenmc: Yep.
Dave Kittle_ DPT: and ah private practices across the street from the hospital clinic, the the full hospital that has an outpatient office in it, or the hospital has a satellite office somewhere nearby.
stevenmc: Yep.
Dave Kittle_ DPT: But the private practice right across the street, all with licensed therapists of the same state, billing the same units, bill under the same ICD 10 diagnosis codes, the same type of patients, and they bill four units and they make, you know, 270 to $300 for that one visit. ah For Medicare Part B specifically, but then it it also pays more for all the payers versus the private practice across the street they bill four units to Medicare Part B and they're gonna make 100 bucks or 109 bucks for the follow visits and maybe 120 or 125 or something for the eval so that is That is something that I think I mean it's it's just
stevenmc: Yep.
Dave Kittle_ DPT: it's possible. I think, unfortunately, we would have to, you know, follow more with what Scott Gardner is doing and United Physical Therapy Association, which I think is going to be doing more in the next coming months um around site neutral payment. And it's not that unreasonable. um And then, and then the example that I gave, by the way, on my show, but so I'll give it here. um I interviewed a practice owner.
Dave Kittle_ DPT: They were they're pretty big in New York City. They were doing like 50 ,000 visits per year.
stevenmc: Yeah.
Dave Kittle_ DPT: um It used to be called Star. it's a huge it's It's the biggest, now they were acquired by Motion, but they were the biggest, private they were the largest private practice of square footage
stevenmc: Yeah.
Dave Kittle_ DPT: in Manhattan, 50 ,000 visits per calendar year. um The practice owner, Ben Gelfand, one of the co -owners, he came on my show. He disclosed all this publicly. So they're doing 50 ,000 visits a year. um I didn't ask him about Medicare Part B specifically, but call that 25 % of their total caseload, all the total visits.
stevenmc: Yep.
Dave Kittle_ DPT: So that was like 12 ,500 visits per calendar year. The difference between $100 of reimbursement of total reimbursement or or total payment per visit versus, you know, $300 per visit. the difference of that $200 difference. So you take the $200 difference times 12 ,500 visits per calendar year. And it was an extra, I think it was like, I'm not running the numbers right now, I think it was like an extra 2 .5 million ah per year, which and all all the other expenses are covered and taken care of.
stevenmc: Yeah.
Dave Kittle_ DPT: All that 2 .5 million literally drops to the bottom line. It would literally be you reinvest into the practice, you open up more locations, you, take out dividends like you you know owner owner draw, whatever, you get taxed on that, whatever. That would be an extra 2 .5 million every every year. um And the reason why I'm saying that is because this is also public knowledge. So Motion and Ed Meersch and Motion PT Group acquired them.
stevenmc: Yep.
Dave Kittle_ DPT: And Ed Meersch had previously, because I worked with them, he was partnered with a surgeon, ah David Mensch, who owned Metro Sports Med. I was one of the clinic directors of one of those seven locations. Dave Mensch had the insurance contracts, Article 28, through the hospital system in Brooklyn, in Brooklyn Methodist Hospital. So all of his, as far as I know, definite definitely one of the locations, but it could be all it could have been all seven locations, but definitely the one main location. had the hospital contracts, so the, you know, $300 per visit compared to the $100 per visit. And so when Motion, Ed Meersch and Dave Minch, and Ed Meersch rebrands to Motion, they they buy ah Star, the very next week or month or quarter, whenever they switch the billing over from Star's private practice billing to the hospital contracts,
Dave Kittle_ DPT: they immediately would have an extra 2 .5 million hit the bottom line just from star physical therapy only. Now again, it was a 50 ,000 visit practice per year, so pretty big, pretty sizable, but it's something that is possible, reasonable, and like I said, hopefully does not require a magic wand.
stevenmc: Yeah.
stevenmc: I would hope not to in your what's. ah I know it's an end of one, but I can't help it. I had lunch with someone yesterday. Not in the world with PT. She's a patient. and like I went to a local hospital here in the Kansas City area. I probably said too much, but anyway. A local hospital are here. she's like you know I had this ankle issue and I went to get PT. and Everyone was always running behind. I got a solid different PT each time I was there for the four visits and you know, saw their billing me like $300 plus and with my plan that I was all coming to me and like this, this can't be what physical therapy is. She went and found a private practice right down the road and paid to your point, like a third.
stevenmc: Um, and like had much better experience and now like I'm going there for life. Like I'm i'm sold on this, right? And it's like, okay, well in what other world do you pay more for less value? And not to say that all health systems are like that. I guess not painting a broad picture, but you know, just to even put a true, like, you know, face and in personal experience to what you're saying. like Absolutely. Now, I'm incredibly biased. like I love my private practice people and um you know that's that's who we work with you pretty much exclusively. and And for a lot of the reasons that that everyone listening to this will probably, you know I don't have to say to to to be able to to know why. um But it does seem wild that that is reality. And then you couple that with the fact that
stevenmc: PTs their debt to income ratio is one of the worst ah in all of health care It might be one of the worst in all like I'm sure there's a maybe a couple of niche You know ah majors or PhDs out there who have a worse debt to income ratio But when I hear numbers like three to one, I'm like, okay. Well if you could do that and so now if I'm looking at you know a PT that's doing 50 visits a week right I'm just gonna do quick math on the fly hopefully it's not bad but if PT that's doing 50 visits a week
stevenmc: um and they're making a ah hundred bucks per visit. Well, so that's 5 ,000, right, that they're gonna generate per week. Now, if they're doing 300, they're making 15. If, as a practice owner, I wanna keep you know roughly, let's say, or you know this number better than I do. What, like if, of the revenue generated by a physical therapist, you wanna keep what, like 30 % of that for all your overhead? every Or like what, 40 % of that? Depends.
Dave Kittle_ DPT: I mean, there's a lot of practices operating around 10, 12, 15%.
stevenmc: Let's just say 20 then so that they keep 20. So that means they're paying the PT for four grand a week, right? Basically seems high So they're one to net 20 the PT gets paid less than that, right? So a hundred thousand i On average so to so the PT keeps 40 % and the PT keeps 40 % of 15 ,000 a week. That's six thousand ah A week to them right then you're talking about making someone in the 200s and that's That's a whole different ballgame right now all of a sudden say okay 300 in debt to 200 in annual income That's I mean then you're talking like kind of that business school type of of math right if hey come get your MBA which if you tack on an MBA to undergrad you're not that far away from 300 and depend upon the school you go to and
stevenmc: All of a sudden, it makes sense, I think, from a financial standpoint to to be a PT. So while I think if you if you said, hey, the the we just need to increase reimbursement, right and and had it as the that that fluffy statement, like, OK, thanks, Dave. right But the fact that it's so specific and like, hey, it's there. We just need to copy and paste this thing. um ah it It seems tough to argue from a a I'd be curious I don't know if you have data on this but it also if anyone listening has data on this please I wonder what the outcomes differential is between hospital and private practice.
Dave Kittle_ DPT: ah ah let's Let's try to be very impartial and I would just go to, I would just get like, I've worked in or had rotations in a couple of different outpatient clinics in a hospital or owned by a hospital. And versus private practices, let's say it let's say it's close to no difference. So then it's like, okay, so why why did they get paid 3x more? um I heard someone say that it was because of the overhead of the outpatient clinics owned by these hospitals, which um the only the only way that there would be extra overhead would be if you have like a
Dave Kittle_ DPT: a physical therapist that's paid, you know, 120 grand a year that's like managing and directing one or more clinics, but it's not producing revenue. Other than that overhead, how is the overhead any different? Like maybe, you know, these, um, These outpatient clinics that are owned by the hospitals, maybe they're using Epic and they're using a more expensive yeah EMR. Okay, maybe. But inside the clinics, they look the same. If not, they have less thrills, ah less of the you know big machinery or things like that. They're not using things like laser or soft wave or thing you know modalities that are cash pay. no There's no hospital clinics that I've seen or heard that are focused around cash pay and cash based physical therapy and out of pocket services or monthly recurring wellness memberships or whatever. like They are strictly insurance based by the book so because because they don't they also don't have to even consider cash based stuff because like they're making you know good margins.
Dave Kittle_ DPT: So i would I would bet that the outcomes are similar. There's gonna be private practice purists out there that are gonna say like, oh, private practice is definitely gonna care more and have better outcomes.
stevenmc: Thank you.
Dave Kittle_ DPT: And then the hospital PTs are gonna say that they have better outcomes. So I think from our perspective, let's call it, the outcomes are similar. Okay, so then why do they get paid 3X more than private practices? So, and let me let me go back, cause you said a ah a couple of minutes ago, something around, is you know is this like the only industry that does this? And as far as I know, it is and it's because of something that is kind of we've kind of mentioned today which is the third -party payer and there there's been great need for a third -party payer whether you know whether it's UnitedHealthcare, Medicare, Cigna, Oxford, Aetna, Blue Cross Blue Shield whatever any of the payers there are a ton of instances where they
Dave Kittle_ DPT: absorb a surprising medical bill. They cover you know all the things that they're supposed to cover. and But then there's brutal instances of the how how it affects someone from maybe not even ah taking their health and wellness seriously when there's a third party payer. What I mean by that is, and and not everyone can pay out of pocket, that's the challenge. there' there's There's the social safety net, there's the
Dave Kittle_ DPT: There's socioeconomic challenges with a lot of folks across the country. So not everyone can pay $200, $300 out of pocket per visit for physical therapy. I get that. I understand that. I'm in New York City and you know we're kind of charging in the range of $250 to $350 per visit. And I know, I say this on every show or interview, whatever, I understand that New York City is a bubble. I understand that
stevenmc: Thank
Dave Kittle_ DPT: people across the country in other states are not able to pay $2 .50 or $3 .50 per visit, whether it's a brick and mortar visit or it's a mobile you know home physical therapy visit.
stevenmc: you.
Dave Kittle_ DPT: I understand it. um But the third party payers, the the insurance health insurance as an industry or or as a as as an aspect to healthcare, provides a lot of good, a lot of support, but at the same time, it has resulted in this being very unique to healthcare, care where you said, where can you go somewhere and you pay less, but you get a better experience? Healthcare care is the only place, right? if you If you come and visit New York City and you are shopping around of where you're gonna stay, you could you could pay, you know, four to $500 or more per night for a hotel in Manhattan, or you could find an Airbnb somewhere and maybe pay, I don't know, like 150 a night or whatever. And that Airbnb might be great, but then also, I don't know, they,
Dave Kittle_ DPT: there's There's other issues with going down the the pay scale of some decision, um you know whether it's whether it's food, whatever it might be.
stevenmc: you know Yep, yep.
Dave Kittle_ DPT: So healthcare care is the only industry that does this, that has this because of the third party payers. Again, there's there's good, but then it's resulted in some of the downsides, some of the negative.
stevenmc: ah Absolutely, there's a a couple yeah overhead. you know One thing that you made me think of when you you mentioned the higher overhead right is is maybe they do have PTs or PhDs or both on staff for research, right a a research hospital. Well, gosh, I don't know I don't know of a single practice owner that I would ask, say hey, you you have to you have to start doing research, but we're going to pay you twice as much. like like ah like You know what the answer will be?
stevenmc: Oh, we get to do funded research? like Of course. It's going to be instant. right i yeah like Oh, now we can afford to be able to collect our outcomes with you know one of the outcomes tools and be able to analyze that more.
Dave Kittle_ DPT: Yep.
stevenmc: Oh my gosh. To quote one of our one of our investors, Um, who, uh, co -founded a very successful PT, uh, group. Um, it'd be like crack in the bird feeder, right? Like you'd be like, you couldn't get enough of it. You could not get enough of it. Um, and, and so, yeah, I mean, if you. count that as overhead, then, gosh, like wouldn't that be great to be able to generate research from everywhere in the country? um I mean, that just, I guess it sounds like an awesome opportunity to me, and I want to talk to you about the third party payer. There's a dirty little secret that I found that not many people know, but I've spent some time in this self insured employer and in TPA, in third party administrator world, and you're, if you are,
stevenmc: If you work for a large employer, what I think 80 % of employers above 500 employees are self -insured, and then they have a third -party administrator, which is the plan that you enroll in that just administrates the claims and the network and their such. and typically the way that let's say Blue Cross Blue Shield makes money is there's a they get a percentage of claims now you start doing quick math they're like wait so if they administrate a hundred dollars in claims and they get three percent then they make three dollars but if they do a million dollars in claims times three percent they get
stevenmc: 30 ,000, right? Am I doing that right? 30 ,000? Yeah, not 300 ,000, 30 ,000. So they're incentivized to have the highest claim volume as possible without losing the business, right? Which then you get brokers involved too, it's a whole thing, right? And and a worth work comp and the shared savings ah contracts that typically are in place with employers like your Sedgwick's and Gallagher's and and others, if they're on a shared savings, deal with an employer, then that's kind of similar. like ah you know Raising that top line isn't necessarily a bad thing, but um while that well that doesn't hit other industries the same because preventative care is covered, so primary care doesn't care at all. right they're like This isn't going to affect us at all because these typically all these visits are covered by insurance and
stevenmc: Uh, your specialist copay is 50 bucks, right? But you're not going there very often. Most likely. Um, right. You're my, my, I have multiple family members with type one diabetes. They're not going to just go see their endo six times, you know, uh, or 12 times in six, in six weeks. Uh, that stuff starts to add up.
Dave Kittle_ DPT: Right.
stevenmc: So I feel like not only is there. It's just PT is almost like falling into this really nasty bites. Um, based on the the current payment structure, especially private practice. um And that kind of sucks. like
Dave Kittle_ DPT: and
stevenmc: that's it
Dave Kittle_ DPT: that That reminds me, you and I talked recently about, I kind of floated it and I said, what if, you know, What if tomorrow there was no health insurance? Or maybe there was health insurance only for people that went through an application process, kind of like Medicaid or whatever, Medicare, like an application process where they actually like looked at your income, your assets, maybe your comorbidities, your socioeconomic status, whatever. um But then the rest of the population did not have health insurance.
Dave Kittle_ DPT: um tomorrow or and moving forward there would immediately be less utilization first of all meaning less total visits ah through physical therapy because now people have to pony up the money because i don't know if you've noticed this but across the country with my colleagues that have insurance -based clinics As soon as someone gets their visits cut off or denied, or they get they graduate or discharged, or the therapist says, hey, Steven, this is no longer medically necessary.
Dave Kittle_ DPT: We hit all your goals. You have full function. You you did your outcome measure.
stevenmc: Yeah.
Dave Kittle_ DPT: And you did you know your ossuestri or your lefts or whatever. You did this outcome measure. And it says that now you're at 80, 90, 95, 100%, whatever. So this is no longer medically necessary because if we keep treating you, your insurance is going to deny it and ask for payment back later. So we have to discharge you. We have to graduate you to your independent home exercise program. And across the country, a lot of the insurance -based clinics will have a challenge with now asking you, Steve, and the patient,
Dave Kittle_ DPT: ah But you can also pay us, you know, 100 or 200 or $300 per visit if you want to come back for the same type of physical therapy visit, but now you pay 100 % of it. a But as an as an exercise, and there's always going to be some folks that truly need, again, the socioeconomic status of a lot of folks, they truly need the insurance, safety net, all that. But it would be interesting to see what would happen ah if people have to pay out of pocket for physical therapy or even like traditional office visits.
Dave Kittle_ DPT: And then maybe maybe procedures are covered. Maybe surgeries are covered.
stevenmc: Yeah.
Dave Kittle_ DPT: maybe Maybe the bigger procedures are covered. But if someone's paying out of pocket, you know a lot of things happen, in my opinion.
stevenmc: Yep.
Dave Kittle_ DPT: Steven, if you're paying $250 per visit out of pocket for physical therapy, magically you and most people cancel less often no show less often you take it more seriously because you're paying for it just like every other industry if you're gonna if you and I were gonna pay for a hotel or an Airbnb or we're gonna rent a car or we're gonna buy a car if we pay for the thing we typically most people will take it a little bit more seriously we We are a little bit more focused on it, a little bit more adherent to the follow through to going through it as opposed to maybe going through the motions.
Dave Kittle_ DPT: And somehow the payers and and all that have rewarded the the hospital systems with the higher reimbursement. But then these they look at the private practices and they're like, yeah, well, there's this history of fraud, the HealthSouth stuff from years ago, the overutilization, which unfortunately is still happening. That's why I believe that there's still Medicare cuts, by the way. that there's a lot of practices that are over -utilizing the visits. They're just billing Medicare. They're they're having Medicare and all these other ah medic these all these insurance beneficiaries coming back for physical therapy when a lot of it is not always medically necessary or it's it's not
Dave Kittle_ DPT: fully required or needed, but patients are coming back because they already paid through their premiums. And they're like, well, I already paid for this, whatever. So I just, I get it. I get to use it.
stevenmc: Yeah.
Dave Kittle_ DPT: So there's so many of these factors. And again, it all comes back to there's this third party payer, as opposed to you and I, we walk into grocery store, we pay for the milk, we walk into a gym, we pay for the membership, we go walk into any other place, any other business, and we pay for the thing and then that transaction is pretty much settled.
stevenmc: There's two things there. I think PT uses would actually go up in your scenario because if I had to pay $500 for an MRI or $500 for an X -ray, I'm gonna go to a PT first, because all of a sudden that $200 starts to look really, really cheap, right? And then it's like, oh, well, gosh, I could go to an ortho. Let's say, again, procedures are covered, visits are not. If I have to go to an ortho, it's gonna charge me 500 and then another 500 for an MRI. Man, I think I want to go like get an email for $200 and get like three or four visits and for the same price and see if I can fix this yeah um yeah i guess kind of myself in a way. so I look at that, like, oh, like that pie, the PT pie would actually expand quite greatly because right now, outside of the resource of time that you have to dedicate to going to a orthopedic surgeon, getting your imaging done, and not to say there isn't a time and place for that for certain injuries, right?
stevenmc: ah but if all of a sudden it was five times more costly to get that done to go the ortho route that it was to go to pt just to get an eval like i think you would see a natural behavior shift happen from from there but um um the overutization yeah and this is where i think that Remote therapeutic monitoring has a really, really great opportunity here to attack that in a way that's not financially punitive to practices, right? And and we see it. We we ran an outcome study.
stevenmc: with a group that we've been working with for for a while now and decided to look at, okay, let's take the same provider group, Medicare patients only, to try to you know hold at least some things constant, and then have a control group of patients who who weren't offered SARA, and then the you know its the study group of patients who were offered SARA. And we very painfully went through the photo outcomes on PDF and transcribed Transposed it into excel and so someone asked me like hey, did you you know, did you take out anyone? Like no way you kidding me like absolutely not it was a you know call it a you know self selecting Type of make sure there was no bias in it What we found was the patience on Sarah and I think this could be any remote monitoring platform that that provides good engagement and good value to the patient, right? So I'm not saying it's a Sarah thing
stevenmc: But the patients on Sarah, they got to a 20, they increased their photo score about 26 points over expected. They did in 2 .3 fewer visits, but at a $47 per episode increase in margin to the practice, right? So I i think there, you look at you look at all the charts and it's like, oh, the CASM, the supply and demand, the demand for PT is doing this, the supply is gonna do in this. like more visits more visits of the same person is likely hurting your business, right? Where, and I know not all the commercials are covering RTM, like I get there's there's more to be had there, right? But gosh, I think there's a ton, a ton of meat on the bone to thinking about how to flip the script on the over -utilization piece.
stevenmc: I know there's a lot of process change. There's probably culture change. There's you being comfortable with risk, right? But as we come back to itul bring it full circle, come back to your first point around adaptability, right? Like you got to know that payers are, they're they're one of the things they're good at is is not paying. And so just don't give them a reason to and be able to and start thinking about this now. for when you come back for that negotiation to to have some data around, hey, here's how we're being really judicious and fiduciaries of your resources, which is your payment to us and why we think we deserve more per visit because of these things that we're doing. um Because I mean, they they they have the claims data, they have all the data, ah except for what's happening in the clinic. And you do have that over them. So in any negotiation,
stevenmc: information is an asset and that's the that's the currency, right? And so, yeah, for for practice owners, I think you're bringing it back, and in really anyone, that the adaptability to bring a full circle to to the start, Dave, is I think that should be the key takeaway from from this from this session.
Dave Kittle_ DPT: but But then again, yeah, like adaptability, that's you need that for any business, any industry, um not to harp on it too much, but there's like, I had to leave a bunch of Facebook groups because there's a lot of negative sentiment on Facebook with different physical therapy or home health or different physical different physical therapy groups on Facebook. I had to just literally leave a bunch of the groups because of folks saying things like, um like people in the south, yeah you heard of Bucky's, right?
Dave Kittle_ DPT: Like and down in like Texas and some of the southern states.
stevenmc: yeah yeah
Dave Kittle_ DPT: Okay, well, they they advertise um a lot and they do great. It's a great business and the they're hiring ah assistant managers or store managers that are gonna make, you know, 105 to 117 something thousand per year. And there's these home health physical therapists. I had to leave the group, but they, they were, they were commenting, like, you know, look, Bucky's is hiring and, you know, I could like make more there or make the same or whatever and not have, you know, the Oasis documentation forms or, you know, go to patients homes and, you know, get cursed at or or whatever, whatever.
stevenmc: Yeah. Yeah.
Dave Kittle_ DPT: um And the that that sentiment ah I think is one one sentiment and then you have a sentiment like you and I coming from a different angle of adaptability um but there's the that sentiment is in nursing it's in the physician you know vertical it's in every profession and every industry where there's gonna be some subset of folks and what I've noticed is that some of the more negative or louder folks are the ones that go on Twitter or Facebook or LinkedIn sometimes or whatever and post some of these negative sentiments and then the folks that are like head down, you know, trying to work on being adaptable, finding different pathways, working with Sarah Health, working with other folks to
Dave Kittle_ DPT: improve the patient experience, improve margins, serve the community, whatever. Those folks are not the loudest. They're head down. They're growing their teams.
stevenmc: very quiet
Dave Kittle_ DPT: They're yeah they they're quiet.
stevenmc: very quiet
Dave Kittle_ DPT: they're not They're not going on these Facebook groups or other places ah to complain about their professions or whatever. um So adaptability is key. I'm i'm just grateful ah for the invite to get on here, for us to kind of chop it up and and talk about our industry. and yeah I mean, adaptability all day. Otherwise, you're going to just you know be complaining.
stevenmc: Very quiet. Very quiet. If you you have time to complain, You probably don't have time to create.
stevenmc: i'm I'm a sucker for alliteration, so that's that's that.
Dave Kittle_ DPT: Level.
stevenmc: Permit will Dave. Another fantastic session. I think we should just continue to do this more more regularly. what We'll pick a another you know nice calm topic for the next one. well we maybe Maybe it'll be myths. I don't know something you know. Something that definitely won't draw you know some strong emotion from from the the listeners. but
Dave Kittle_ DPT: Oh, what i've what I've, real quick, what I've learned from my show and my podcast is that you absolutely want to talk about the challenging topics. No one really cares about MIPS or some of the other, you know, HIPAA compliance, what like, yeah, those are kind of important. But the things that get the most interest on my shows are the the polarizing topics.
stevenmc: huh maybe uh I don't know I'm thinking through like gosh PT vs OT that could be a fun one maybe get uh Rafi Salazar on for for that one um with with his background that could be uh yeah that that that could be a fun one um or maybe you know PTPTA it's been interesting to see
Dave Kittle_ DPT: There you go.
stevenmc: and it Just this is from my guess lived experience with Sarah some of the some of the some of some really great leaders and clinic directors and and even practice owners are PTAs and It's just interesting to see but they like, you know, you got to think about what they know like they know all like all the the ground ground foundational level not say that PTs don't but again, it would it would elicit emotion for sure um I don't know, maybe maybe a cage match, PTOT.
Dave Kittle_ DPT: Now you're talking.
stevenmc: I don't think that would be a tough ah tough, maybe we'll throw an ATC in there too. Maybe one of the lifetime dynamic personal trainers. How about that?
Dave Kittle_ DPT: Yes. So that that that whole thing we've covered on the Breakfast Club PT show that we do live. Yeah, exactly. So that you know that specifically, that that topic with lifetime PT or lifetime personal trainers with the DPT on their shirt, because they're calling themselves dynamic personal trainers, but they they're doing it on purpose because of DPT, because of doctor physical therapy. ah Yeah, so we we talked about that. That was an episode. So that's what I'm talking about. And as a sidebar, so on my show, The Dave Kittle Show, the video that's got the most views, and I'm not saying for you to totally adopt this, I'm just saying this is my perspective. You're you, you know, because you represent Sarah health, you want to kind of be very, you know, you want to be
Dave Kittle_ DPT: respectful, right? I'm a little bit more irreverent. But my, ah the most views the show that has the most views or the most the episode that has the most views on my show on YouTube is an episode that I that is titled hinge health is dead.
stevenmc: Thank
Dave Kittle_ DPT: because, so I think it was last year, so twenty twenty three early March or April or something of last year, I had a conversation with this practice owner that does mobile visits, ah Brian Williams, and we just chatted about hinge health because he sent me a link and it was hinge health moving into in -home
stevenmc: you.
Dave Kittle_ DPT: visits, in -home, physical, in -person visits.
stevenmc: yeah yep
Dave Kittle_ DPT: And then ah the whole theme of the episode was me saying, this was me, and my you know not not him, not anyone else. I was saying, well, obviously, Hinge Health is dead because their core technology is obviously not great, because if it was so great, they would never move into home visits. They would they would continue to be the ortho like virtual
stevenmc: Yep, yep.
Dave Kittle_ DPT: a virtual platform, why would you ever then go into home visits unless, you know, it just doesn't, it didn't make sense, right? So that was a very polarizing headline and topic. We had people commenting, patients of hinge health on YouTube commenting like, no, this is a good program or whatever. So great, right? But like, um it was it was polarizing. And if if we potentially use that angle of some polarizing topics, then my voice can reach more folks across the industry.
stevenmc: Yeah.
Dave Kittle_ DPT: I'm not so i'm not saying for Sarah Health and Steven and you guys to do this with the show, but I'm just saying that's that's that's typically one one thing that can work.
stevenmc: Yeah, that's there's there's one thing that I've been kind My background right is is as a patient, but also doing manufacturing supply chain consulting. right and so you know Something that i've I've said a couple of times recently, and I've gotten like a little bit of like a like cringy, like, yeah, I see what you're saying, is one of the things that we did was talk to folks on the manufacturing line and figure out how we can rip away any administrative tasks or like additional burden on them. right like What's distracting,
stevenmc: what's annoying, just just those questions, right? And and I've gotten, again, its that cringy like agreement of like, it's not exactly the worst way to look at your staff PTs either. It's like, okay, they are there to treat patients and it mirrors an assembly line more than you probably want to say it does. But like you have a certain amount of time to block that you provide the treatment and like, then there's after like kind of block it off in the same exact way. Um, and not that I'm equating, you know, putting rivets, uh, into, uh, you know, Boeing seven 37 as the same as treating, you know, your mom. Uh, but it's a process. And so if you are bombarding your physical therapist with communication across multiple mediums and alerts, like
stevenmc: and you expect them to be able to be focused with that patient, it's it's unrealistic. um and And I think we could do with some more like looking at other industries and just seeing if we could take a ah page out of their playbook or copy and paste some of the learnings. And so, yeah, I hear you on the the brand and and not wanting to be a reverend and all of that, but there are definitely some like thoughts that I have around maybe we we should take a page out of ThyssenKrupp's playbook, right? And what they've done with their elevator service texts and some of the experience that I have been working with them, like, not all of it just because it's outside of healthcare is irrelevant. But that's a, again, longer, longer discussion. Dave, I, there's a part of me that doesn't want this to save. So we can do this again. But there's a part of me that does to make sure that people can hear it. ah You mentioned the Dave Kittle show, where else can people find you?
Dave Kittle_ DPT: ah If you type in Dave Kittle, you can find me on LinkedIn, Facebook, Instagram, Twitter. Just type in my name, you'll find me.
stevenmc: Perfect. That's easy enough. ah Dave, anything you want to leave the audience before we wrap up?
Dave Kittle_ DPT: No, if you're a practice owner looking to take some chips off the table, maybe there's a potential partnership for us with you. Maybe you retain some meaningful amount of equity, or if you're looking to sell your practice, reach out to us, fieldmakergroup .com. If you're a physical therapist looking to potentially relocate, and ah if you're looking for mobile concierge visits, either part -time or full -time, feel free to reach out to us at conciergepainrelief .com. Steven, thank you so much for having me on your show. I truly appreciate it.
stevenmc: Absolutely, Dave. Thank you very much. It's been a great one. And with that, bye, everybody.
