Reversing The Reimbursement Decline - Scott Gardner, PT, DPT Of The United Physical Therapy Association

[00:00:00] It has taken me a long time of really studying all this to understand the nuances of the healthcare system and where we sit. And we don't sit at the top, we are at the very bottom. But all therapists and their patients know how much value we bring to the system.

[00:00:18] Welcome to the Private Practice Owners Club. Your hosts and coaches, Nathan Shields scaled his practice and exited for millions, while Adam Robin went from working 60 hours a week in one clinic to scaling to multiple clinics while working less than four hours per week remotely. This podcast is meant to share with you exactly how they did it and how you can build a business that supports the lifestyle that you truly desire.

[00:00:42] And don't forget to join the Private Practice Owners Club community on Facebook, where we are obsessed with providing even more resources that help owners, just like you, win the game of private practice. Hello and welcome to the Private Practice Owners Club podcast. I'm your host, Nathan Shields. And I've got Scott Gardner of the United Physical Therapy Association and owner of multiple clinics under the name of Gardner Physical Therapy in Maryland.

[00:01:12] Scott, it's been about a year and it's good to hear from you again. Thanks for having me back on. Good to see you. Yeah, it was great to have you at the conference this past October and all the information that you shared and the capabilities that grassroots campaigns like yours that can affect change. It was good to hear about that. It was also really good to hear about your ideas about how we can become more valuable.

[00:01:36] Frankly, how we can make more money, how we can reverse this decline in reimbursement through your presentation at the conference. So many great ideas that I saw you put forth that I'm excited about. Not that all of them will come to fruition, of course, but I love what you were able to present on. Thank you. Yeah, I mean, I think as our profession moves forward, we need to position ourselves as the primary care for musculoskeletal issues.

[00:02:03] Shall I say neuromuscular skeletal issues? We need to be the primary entry point for that. We have a lot of work to get there. You know, in the Medicare system, we are considered suppliers and we're ancillary. And the ancillary tag really holds us back, even though our profession has moved forward with a doctorate degree. The ancillary designation by Medicare is the reason we have MPPR. It makes us basically staying underneath the physician-driven model.

[00:02:29] So in order for our profession to move forward, we really need to work on being able to not be called ancillary anymore and be independent practitioners of medicine within the Medicare system. And now we have direct access in many states, but that's for commercial payers. We really need to get out from underneath that ancillary service, ancillary provider tag. And that's one of the reasons why we have the, hopefully the opt-out litigation that we're doing will help allow us to elevate ourselves slightly in the profession. But that's just a stepping stone.

[00:02:59] I cannot do all this myself. A small group of members cannot do this by themselves. This is going to take a united front, hence the name United Physical Therapy. All of us in all settings need to work together. And I'm like, why are we doctorate level providers if we're not going to act like that? You know, if we want to be underneath the physician model all the time, then we should just start with a bachelor's degree.

[00:03:25] So we got the doctorate level, but we never got rid of the regulations that keep us grounded and at the bottom. So we can discuss all these issues. I try to tie them all together so people understand it better as to why things happen. Because I think, I mean, it took me, I talked to you a year ago. Yeah. It's taken me a long time of really studying all this to understand the nuances of the healthcare system and where we sit. And we don't sit at the top. We are at the very bottom.

[00:03:54] But all therapists and their patients know how much value we bring to the system. And we all know how much money we save. So we can discuss that a little bit if you want to. But I don't want to bore everybody with details. But I do find it really interesting as to how we got to where we are and how we can try to move forward from that. Well, you bring up some great point right off the bat is, and I want to eventually come back around to what you've noticed or what you've learned in the past year, what some of your efforts have entailed.

[00:04:22] But since you brought it up, what would it take for us to no longer be considered ancillary? Is that just, do we have, is there a group that would push back heavily upon that? Yeah. Or are we just not willing to stand up for ourselves? What's keeping us from moving out from under that ancillary tag? Well, physicians are going to want to prevent us from becoming more autonomous for one. Why would they, then why would they want that? Because they just want to control the... Okay.

[00:04:51] So they want to stay the gatekeepers. 100%. A gatekeeper. I think we need to carve out where we help. So we're not going to be the primary access point for everything. But we're going to say, look, you know, I did a small little conference that was put on here locally by the orthos. And they brought in the primary care. And it was basically how to, for the primary care, is how to basically tease out the patients that need to go to the orthos and which ones don't.

[00:05:15] It was the lecture was very, as a physical therapist looking at it, like, yeah, this is stuff we know at the back of our hands. But they're educating the primary care providers on what to look for. And I'm thinking, like, this is, like, exactly what we talk about. Like, these people should come into us first. Because it basically said, if they have X, Y, and Z, send them to PT first. And if that doesn't help them in six weeks, then send them to us. And we'll do the imaging and find out what interventions they need. So... That sounds pretty basic. Right. So, like, why are...

[00:05:44] And those PCPs, they've got a ton of stuff to deal with every day. Yeah, they've got plenty of diseases coming through that they can focus on. Right. So, like, we need to position ourselves at that front point. And how do we do that? Well, look, there's, like, 300,000 of us in this country. We all, like... Everybody likes to seem to type on Reddit and complain. Go on Facebook, Instagram, and what have you. But we need those voices to come together. Especially when there's periods of the Medicare physician fee schedule, proposed rule come out.

[00:06:12] Also, when there's opportunities, if we push something forward, to go to regulations.gov and push our voices out. Speak with our congresspeople locally. And just be more vocal. That's the only way we get this changed. I think a lot of this issue has to be changed legislatively to get us to be in that position where we're not ancillary. But I think our opt-out litigation that we're doing could be a first step. Because it really... In the motion to dismiss from the government, they really spoke highly of what we do.

[00:06:41] That basically, we are so important to the Medicare system, they cannot allow us to get out of it. That's one of the quotes. Not per se, quote, unquote. But that's what they were basically saying is we're so important to Medicare that we don't want you... We don't want you to leave people not having access to your care. So they call us self-care professionals in that motion to dismiss as well. Even though, from a loan standpoint, we're just considered graduate students. So I found that to be interesting because a different section of the government called us self-care professionals.

[00:07:10] But I think we have leverage on the state we have. You find in pushing the opt-out legislation or the opportunity to opt-out as leverage to kind of force their hands into... Would it be a win if they said, okay, we don't want you to opt-out, but we will take off the ancillary tag? I don't think that'll happen. You don't think that'll happen? Okay. No, I don't think that'll happen. So I think when they opt-out, I think it just helps position us a little higher. Okay. We need to be...

[00:07:40] Look, we can't lead any type of these CMMI models, if you're familiar with that. That's the Center for Medicaid and Medicare Innovations. Those are the ones that create these value-based models, like the AHEAD model, the ACCESS model, total cost of care. We're downstream on those models, so we can't really lead it.

[00:07:57] We did put a proposal in to CMMI about doing a value-based model with us for low back pain, fall risk, things like that, where we show the costs for us to do a treatment plus the outcome. And then you have the other pathways they might go, whether it's surgical injections, things like that, to demonstrate our value. Because what Medicare looks at, from my understanding, is they look at what their data says. And they're looking for their data in terms of where the cost containment is.

[00:08:26] And we need to work directly with them to try to get us to have access to some of these models and move forward. So are you telling me that APTA has never put forth those models? I don't believe they have. I don't believe they've pushed forward a model. I looked all over the place, and I could not find where they were submitted a model. I am not aware of them doing that. I don't know why. That hurts. I mean, maybe they'll come back and say we can't because we're ancillary. We don't know unless we try, right? Right. We have to figure out if that's the reason why.

[00:08:53] But we should be leading some of these models, especially in the care that we provide for back pain prevention. Those are like big things for physical therapy. Right. Even knee pain. I mean, you name it. Yeah. All the osteoarthritis problems they have in the older population. So we need to do that. I think that would be very important if we can get some type of proposal where we could lead a study. Even if it's a small sample of like 50 outpatient clinics across the country in different MACs with different areas, just to kind of demonstrate our value for a year or two.

[00:09:22] And then they can compare that data as we move forward. I've reached a bunch of different organizations that work directly with CMS. They all say like it's fee for value is what we're going shifting toward. Like you and I have practiced in the fee for service. Volume equals money. And our healthcare is shifting to outcome-based. Yeah. And how do you see that model playing out, say in the next five to 10 years?

[00:09:50] How are they going to reimburse us for value when there is nothing that incentivizes us to create value? It only incentivizes us to generate more CPT codes. Right. So I think what we'll see is a shift away from the fee schedule. And if there is, it might be, they might just give you a, okay, here's a new replacement. I'm going to give you $2,000. Manage it. Best you can. And you might get paid based on the fee schedule.

[00:10:18] But after a certain amount of time, if you can get them, if you get a person better, have good outcomes, and it's only $1,400, then they're going to give you the best. I think that's how these models work. Don't quote me on that. Okay. But I think that's kind of how it works. It's like, we're going to give you money and manage it. I know in Maryland, we're a total cost of care state, which is the only state in the country that has it. So basically they give hospitals a large sum of money and say, take care of the patients in that area. Right. And so they have to manage outcomes. So that's where we will come in handy.

[00:10:48] It's like, okay, we could up, reduce your costs because we could do X, Y, and Z in the home setting and then transition in them. So they don't go back for a readmit within the first 30 days, they have to discharge because that's where the costs go up because they weren't taking care of and managed well outside. We fit so well in every aspect of healthcare. It's just that we are just kind of, we're just kind of like an afterthought. Right. We're just an afterthought.

[00:11:13] And so it sounds like then the ancillary tag, getting that taken off of us, that is pie in the sky decade or more down the road. Probably. But speak of ancillary is like a physician can have a physical therapy office because it's an ancillary office product. Right. So what are the other things that are ancillary office? It's labs and diagnostic testing, imaging. Right. So MPPR is only applied to things that are ancillary. It's not applied to anything else.

[00:11:41] It's only applied to imaging and diagnostic testing done in a physician's office. And of course, us. Physical therapy. So like if we can get rid of that tag, that would be good for us. And in theory, would we still be ancillary in terms of the physician can have a physical therapy practice? I don't know. But you know, there's nothing wrong with working for a physician practice. I'm not saying that's a bad thing per se, but why can't we, I know some states may let you, but we should, if you want to join a physician, you should be able to partner with them.

[00:12:10] So you can both benefit from the, from the, uh, the treating patient and not just be a, an employee of a physician. But that's just my personal opinion. But I really do think we need to get rid of the ancillary tag at some point, uh, to really kind of just elevate our profession. Gotcha. And then I know you put forward the opt-out proposal this past year. Tell us the effects of that. So that's something that's happened since our conference. If I, if I remember. Yeah.

[00:12:35] We filed a suit against the HHS basically to allow us to, for equal rights, uh, constitutional effect on our equal rights, uh, as a physical therapist to not be able to see patients in the Medicare system. Um, it took a while for the government to respond. They responded in February with a motion to dismiss, which is, which is normal. Basically the rationale was, um, uh, multiple things. Let's go through and see, uh, reduce access to care. Uh, we would be more fraudulent, uh, in the system.

[00:13:02] Um, continuity care might be disrupted and, uh, it could destabilize Medicare. Uh, so we responded in kind to those issues and said the opt-outs aren't existing for, you know, physicians, uh, and it hasn't destabilized Medicare. And I honestly, I think a large percentage of physical therapists would not opt-out. But that being said, what if you live in an area where there's one pelvic floor therapist that's right down the street and they decide that they're just doing catch-based therapy. And the next pelvic floor therapist is two hours away in a hospital.

[00:13:32] Uh, and then what the patient has the means to be able to afford that physical therapist, you're really reducing your access to care by making them drive two hours to a hospital instead of being able to negotiate into a private contract with, with a person. So, um, that, that's really the gist of it. I mean, most of us aren't going to opt-out, but I think it just, it's all about just the, uh, the quality in the system. You know, dieticians can opt-out, but we can't. Oh, really? Yeah.

[00:13:58] It's like, I don't, it's just, I don't know why these are all just written into law by the, by Congress in the balanced budget act 1997. I gotcha. So why did you start there at the opt-out option versus other things? And what are some of the other things that you're looking forward to here over the next year or two? Well, our attorney reached out to us, uh, with Pacific legal, um, their nonprofit. And they reached out to us and said, we'll be interested in this, uh, in entertaining this opt-out litigation. Are we ready through?

[00:14:26] And I was like, yeah, we should be able to opt out. And I think right now HR 4204 is in Congress and it's a basically patient Medicare patient access bill, I think, which is basically the ability for us to opt-out. So we have it going for the APTA through the legislative side and then us trying on the litigation side. So maybe the pressure of both. Nice. Uh, maybe enough to push it over the edge to get us to be able to opt out. So that was our first, uh, when they reached out to us, we, we discussed it as a board and said, let's, let's do this for the profession.

[00:14:57] And it sounds like you're doing that in coordination with the APTA, like you said, from the legislative side. Well, they're everywhere from the legislation side. They don't want to participate with the litigation side. Okay. So they're, you're not necessarily collaborating on this. It's just happening to come together at the same time. No, not at all. I mean, you're thinking both things are coming together. They, you know, they could see it. There's a legislative aspect over here and then the litigation over here. Maybe I'm like, oh, okay. Travers in Congress, people to say, let's just get this figured out. That's the hope.

[00:15:24] And then MPPR is something I looked at for, oh gosh, for about six, seven months. And, um, flew down and met with the attorney general of Louisiana. Uh, she gave us the idea for, of a petition. And I was like, what's a petition? And she says, anybody can petition CMS for a rules change. Okay. So I spent another three or four months really diving into the MPPR when it started in 2012, how it was originally written. It's written in a statute. Uh, and then CMS decided to apply it how they, they thought it would be appropriate under their eyes.

[00:15:54] It was just a 50% process expense reduction. Mm-hmm. Ours. And then CMS decided to apply it to always therapy codes. So we're basically petitioning CMS to re-examine how they do it. And we're asking them to reapply it such that if I bill 97110 twice in a session and I do 97530 once in a session, the only MPPR is applied to the second duplicate unit. Yes. I see that.

[00:16:21] I mean, 530 is paid in full. The first one, one of those paid in full. The second one. Right now it would be all, the second two units would be, you know, wiped out. Um, so that's, that's what we're asking them to do. And in theory, a petition means they have to look at it and they have to respond in kind as to why they decide to do what they did. So my ask is going to be when we get to the proposed rule to really flood CMS with questions and comments about MPPR.

[00:16:50] We did it last year for our association and CMS did comment in their final rule that MPPR was brought up a lot in this proposed rule, but it really had nothing to do with this proposed rule. But it was a little blurb in there enough that they saw it. So voices do matter. Okay. And, um, when I met with the APTA last week, I just guessed them, you know, a great thing for our profession would be there's like 25 to 30,000 students in any given year.

[00:17:17] If we would have an advocacy day in September and the first week of school back in the fall semester, we could flood CMS with a lot of comments from students as well as professionals. And that would probably push it to 20 to 25,000 comments just from our profession. I think last year we had like 2000. Oh, wow. We have to read every comment. That's the best part about it. So like our schools have a great opportunity to be advocates for our profession and schools really need to be a part of that. They can.

[00:17:45] And I'm hoping that we can, we can make that work where we can get the students to be more involved because what's coming out in this field. I just want to leave it better than when I want them, when I got here and right now it's, it's struggling. Well, you're doing a great work so far. So, uh, I hope you don't get discouraged. You're doing awesome stuff, but I'm, I'm curious. What did the APTA have to say about maybe recruiting some of these students for some support? And they just kind of like, uh, they really say much about it.

[00:18:14] Um, it was a, it was like a 35 to 40 minute meeting last week, just kind of going over different, uh, policies that they're working on and what we're doing and answering some questions back and forth. Um, we left on great terms and I'd like to be able to work with them even going forward on topics that we can agree upon. Um, I said, I'm more than willing to help get the voice out there to help assist and, uh, getting some of these legislative issues to the public. We all as a profession need to work together. It's everything that happened in the past is in the past.

[00:18:44] Let's move forward. Um, you know, we'll keep growing our association and they can hopefully keep growing theirs. And the more voices we have that come together and unite, the better we will be. And we'll keep doing things our way and, uh, we'll reach out to them when we have something that we're doing and see if they want to be a part of it. And if they do great, if they don't, we'll keep plugging forward and moving ahead. So, but I really want to try to work together as much as we can, um, going forward so that we can help the profession out. They really are trying, um, to help the profession.

[00:19:13] They take a legislative approach and that just takes forever. Well, and they're obviously their focus is not on the private practice owner. A hundred percent. And so, um, that's where we can cast a lot of complaints is on that. It's not focused in reality mostly, uh, and what reimbursements look like on the ground. But if, if you were to say, if you were in front of them or if the APT came to you and

[00:19:40] they said, we want your help on this, Scott, what's the one thing that could come to you about and need to be over the moon excited about, because you know, the combination of your two efforts could make really make a difference. Is it something that we've already talked about or is it something else? Payment, administrative burden and student debt, loan debt, all three things that I would definitely help with in terms of reaching out. But I think payment is the biggest issue for most all of us that are owners in private practice.

[00:20:08] So is it something outside of MPPR or opting out legislation? Is that, or is there something else that man, if, if we really got together on this, we could make a huge impact. I think MPPR. MPPR. Now I know, I think they're going to try to push forward a bill for that. I think we all realize it's a, it's a flawed, flawed policy. Um, but I think if we can really push together for MPPR, uh, CMS can make some changes. They're allowed to move money around. Um, but we, we have to be heard.

[00:20:37] So I think if, if we can get it to, to stop doing it to all the codes after the first one and just do the duplicate ones, every clinic will probably make an extra 10 to $15 at least. A visit. That'll put everybody into the green again, or the black or whatever you want to call it. Uh, it'll help clinics out immensely. I mean, the thing is with Medicare, when they, when they come up with something, all the commercials just follow suit, like blue cross. Oh, MPPR's a great idea. I think they'll apply it to our patients too. You know, they all start applying it.

[00:21:05] And so what comes from Medicare always trickles down. So federal policy is very important, but I think if we can get behind that, and I think we really, really need to push the proposed rule. We really need to get our voices heard. I mean, there's just, there's so much apathy out there. I mean, if people would stop just punching it on the Facebook comments and actually do something constructive with it, but they're five minutes, it'd be much better than arguing with somebody on Facebook about the X's and the Y's.

[00:21:32] Uh, that's what gets me frustrated when people say, come on, you can do more. I'm like, what do you mean? I can do more. How am I supposed to do more? What more do you want me to do again? Like, you know, you guys need to do this. I'm like, who are you guys? Like, you want me to say that to the APJ, work harder. I'm like, it's a volunteer organization. It's like little league, you know, there's only a handful of people that I put the effort in. So like y'all need to join. If you're not happy with it, join or join us and do what we're doing, but just don't stand behind the keyboard and complain.

[00:22:00] That's why I love getting in front of your audience of a hundred people last year, just to tell everybody what we're doing. And it's like, wow, I've never heard of you guys. This is great. I'm just trying to bring hope. There's a future for this profession, but we're not going to have it if we don't all stand up and start doing something about it. Well, I remember saying something about this last time we spoke, but what Adam and I are doing with private practice owners and trying to help them run their businesses better, become more profitable, gain more freedom, more expansion, et cetera, et cetera.

[00:22:27] It feels like we're just playing with the cards that are dealt, but you're dealing from the place of working on the house, if you will, and dealing with the dealers. Like maybe the rules can change. Maybe the odds can change. If we change the cards up a little bit, you're dealing from a different, at a different level and both are valuable. But if there's going to be lasting change, it really needs to come from a legislative federal place versus what we're doing on boots on the ground.

[00:22:55] The combination of two can do amazing things, but significant change has to be made. A hundred percent. I really do think we can do something with MPPR if we keep watching because in Medicare, CMS can move the money around. It's arbitrary and capricious are the two words that describe how they apply it. They just apply it. And nobody knows why. Why did you decide to do it to every code that comes down after one? And now, if I have an OTC in the patient after me, all their payways are cut too.

[00:23:23] I mean, it's just, it doesn't really, I don't think that was the intent of Congress. I think we just kind of let it slide for five or six or seven or eight years because the conversion factor went up every year. Man, we're still getting a bump. Well, then when the conversion factor started going down in 2020 or 2021, now it's like we're getting a double hit. We got 20% cut there. We got a 15% cut for PTAs. And now we got MPPR. I mean, how much more can sequestration? Don't forget that like 35 cents sequestration. So, I mean, it's like, it's just nonstop.

[00:23:53] And I do think that we can, our petition is, we have an executive summary on the front so people can, when they get it, they can actually read what we're trying to do. And that's about 13 pages in depth. We had a turn and read through it to make sure all the legal aspects were correct. And we're eager to see what comes of it. But I'm going to ask people to start writing into CMS and asking them really to look at this petition. I think they can make some changes. They can put money around. You just have to realize that they can move the money around.

[00:24:22] People don't realize that they can't make the budget bigger, but they can move it around. But we have to show them why, and we have to show them the value. So that's why we want to have a proposal. It demonstrates our value in the healthcare system. Look, none of us are looking to get a lot of money per visit. How about like an extra five to $8? Right. Can we get maybe on the other side of inflation? Right. I'm going to convert it to 3% over here. Right.

[00:24:50] The economic index, you know, that would be nice. Yeah, that'd be great. What about indifference to place of service? What do you think the possibilities are of eventually moving things such that we get more like with the hospitals or vice versa? They become more like this and they're reimbursements for similar care. I don't know.

[00:25:15] I mean, site neutral payments would be a solution, but I don't know if that's ever going to happen. I think one of the biggest issues we have in healthcare is, you know, we've gone from, I think, 75% independent physicians to like 15% independent physicians. Ooh, yeah. In the last like 20 years. So it would be hard for us to get site neutral payments. Too many lobbying groups out there to fight against them, sure. Yeah, there's a lot of like, you know, a lot of the lobbyists are pushing, you know, to

[00:25:44] keep it the status quo. But I think the biggest thing is educating the public that there's a cost differential between where you go. And if you have a high deductible, you're going to pay about half as much if you go to John Doe across the street who's independent than you want with system. But there's just so many issues. There's so many, it's just so many things that are out there that are creating a system we're in right now and it's really big. So I, you know, how do you meet an elephant? One bite at a time. Yeah.

[00:26:13] So pick your battle. Let's choose MPPR. We know if we can win that, we'll get an extra $8 to $10 per visit. That'll be a huge thing. And then that'll give us the flexibility to, for us, for one, help patients to compete maybe with the systems as you try to hire people, offer more benefits for your employees and things like that. So, but we all, we all have to band together. And I know advocacy work can seem really boring, but honestly, it's not, it's kind of fun.

[00:26:40] And you have to understand the systems that we live in and why things are the way they are and to really understand where you need to go. And where would you go next after MPPR? What do you have, does Scott Gardner have a vision board of where he goes next after maybe this opt-out legislation or the MPPR stuff? I'm going to retire. Honestly, I don't know. I haven't really thought that far ahead because we've got this.

[00:27:09] I do actually, I want to, I take that back. One of our goals is to create like an independent practice association, which is a network of independence, maybe a clinically integrated network, an MSO. There's like three different concepts you can do. Okay. I do believe that for the future of independence, we are all going to have to unite at some point underneath one of these networks to stay viable. So the network. Would they be state led or regional or does it matter? We're trying to figure it out.

[00:27:39] Like, I think we mostly buy state by state, but I think you can cross, you can have one cross into other states and move forward. But that would allow us to have basically more leverage in terms of like how we buy things, our compliance, our purchasing power for insurances in terms of like now practice, general liability, things like that. Everybody stays independent underneath the umbrella. But now compliance is run under one main organization.

[00:28:07] Credentialing is run under one main, like the MSO. The HR is under the MSO. So all these costs can be combined under everybody. Since I have one person that's such an HR manager for five clinics, now you have, you know, 50 clinics with, you know, five HR managers. So the cost is spread out. And it allows you to, you know, eventually if you're a clinical integrated network, you're working on value-based care and outcomes. And then you can start negotiating with payer contracts via IPA.

[00:28:35] So all these three can kind of work together to make your own little system within your state. And if you have a hundred clinics in one state under one umbrella and you go to Blue Cross and you say, I'd like to, I'd like to work with you. And they're like one contract. That's it. Yeah. One contract. That's it. It's going to be a lot easier to work with these insurance companies. And I think that's where, you know, I think we're too fragmented, right? You know, and we don't, and the funny thing about PTs is we don't really work together very well. Like the person down the street, that's my competition.

[00:29:04] Like, no, that's my colleague. That's that I'm older. That's how I think of it. They're my colleagues down the street and I interact with them. But other people are like, that's my competition. Like there's enough business to go around. There is. I, it took some actual numbers to help me understand that. But what is it? Something like 10% of the people with musculoskeletal issues are actually getting to physical therapy.

[00:29:27] Many of them, a slightly greater percentage of those people are going to a physician, but they're usually getting treated with medications and sent over to the ortho or something simple like that. Or nowadays, maybe they're just talking to their AI doctor and right. And getting the care that they want. But there's a small portion of people with musculoskeletal issues that are actually getting to the therapy. And so there's a lot, when you say there's a lot of work out there, there is.

[00:29:56] Well, that's why I like, that's why Hinge Health and those companies are taking off. They're doing direct to employee contracts with, you know, and basically saying, we'll take care of your employees. And it's, uh, it's, it's part of their package for their healthcare benefit. Right. And so these are things that like, these are all things that we have to look out for in the future. And, and these people have come up with ways to, to leverage AI and digital platforms to move forward. And, um, we can't, yeah, cause the demand is there. Yes. Yes. A hundred percent.

[00:30:25] So there's so many things to work on. If I didn't have this private practice to run all the time, I'd have a lot more time to focus on anything, but we've got, you've got so many things to work on AI aspects of digital care, fixing the front desk issues in terms of how do you, how do you automate that as you guys work on all the time in your clinic, automating the front desk. I mean, it's just so many things that we could do, but it just takes time. Yeah. Yeah. The, when you brought up the IPA slash MSO model, we've seen that work in Arkansas. Have we not?

[00:30:54] Aren't they using an IPA for a number of independent practice owners? Nope. I believe there's a huge one in Arkansas. And they're doing it very successfully in terms of their reimbursement rates and dealing with insurance companies, et cetera. Yes. And I think it's that, that's the future you need to, we need to band together, but you just got to make sure they all understand. You can still be independent. You can still make your own decisions, but we're going to share our outcomes or I share our protocols.

[00:31:20] We're going to share our data so we can demonstrate that we can get a load back pain case better in 7.95 visits at a cost of, you know, X amount of dollars with the insurance company. It's like, okay, I can appreciate that. You know, I mean, that's, that's, that's what it boils down to. Yeah. And if we can actually show that in practice or like you even said in some of those CMMI edits or audits, right? Yeah. The data that's, I mean, if we can get like into a proposal, we can actually demonstrate our value.

[00:31:47] That's the biggest thing is we know we're great at what we do, but in our patients that come to see us love us, but we just have to demonstrate that nationally. Like our identity nationally is, it's all over the place. And there's, there's gotta be something more to it because I know we've been pushing that a lot, but even when I, I hear from someone at the APTA at PPS, he said he was talking to a high level executive at one of the insurance companies.

[00:32:15] And he's like, you know, you keep decreasing reimbursement rates for us. And can I ask why? Like, what's the logic behind it? What are you seeing? What can we do differently? And he's like, you want to know why we pay you less? And he's like, yeah. And he said, cause we can. And so I think sometimes it's just that simple that we might be looking for what is the secret sauce and what, what kind of levers can we pull? But sometimes it's a matter of, like you said, putting our foot forward, maybe banding together, changing legislation.

[00:32:45] We got to work at higher levels and to actually make impacts. Yeah. Rick Owende always puts out, he puts posts out a lot and he always says, it'll be a best of a network of physicians or such as hospitals opting out. I think I had one the other day is like, why are our PTs opting out? You know? And it's, and it's true. It's like, but I think, I think it comes from why we all got into this profession is we got in the profession to care for people. So the money was never really an issue for us. We just figured we'd make a decent living and we'll take care of Mrs. Smith. Yeah.

[00:33:15] And when Mrs. Smith can't afford her copay, I don't know, I'll stay late and I'll take care of her for free or, or I'll do this and I'll do that. So it's hard for us to ask for cost sharing on the patient side. Like, I don't, I can't believe we're going to charge them $90 for today. I was like, yeah, because you want to make a hundred thousand dollars and that's at $50 an hour without all the other stuff. So it's like, there's a disconnect. And I think our, we're just so altruistic, right?

[00:33:43] We care so much about people. That's why all of us are in this profession. And I think sometimes that hurts us because we have a hard time saying no. So when the insurance company says, I'll give you $45 a visit, where are those patients going to go if I don't take that? This is true. No, I don't want them to have to not be able to care. I'll see them, but I need to have one-on-one for an hour. Yeah. It's like, it doesn't, the math doesn't math. And I think that hurts us. And I mean, obviously I opted out of a couple of insurances and it really hasn't hurt us

[00:34:13] that much. Right. This year, just some of the ones that, most of the ones, it wasn't so much the dollar amount. It was the administrative burden. Yes. And God was spending 50% on 10% of my practice. I'm like, this is ridiculous. Like you're paying us peanuts as it is. And you want me to ask for off every three visits? Like, no, we're done. Well, let's be truthful about it. The insurance companies that are paying you some of the worst reimbursement rates are the ones that have the greatest administrative burden. Well, it's crazy. Yeah. Crazy.

[00:34:43] So you need to like get away from them. You know, it's a bad relationship. Don't stay in it. It's like staying in an abusive relationship. 100%. And when the patients start to realize they can't get care of anywhere, guess what they'll do? They'll shift to another plan next year. Right. Yeah, exactly. Exactly. Who's that? So, but yeah, we're just all true risk to it, man. We just care too much. And I think some of the times that's one of our problems is we care too much. It is one of our downfalls.

[00:35:08] We are a collective industry of people who like to be liked and we will be submissive to whomever we need to be submissive to in order to be liked and play nice. Right. It took me a long time to get over that feeling. So when I started this association, I knew I wasn't gonna have everybody liking what I was doing. So it took a while to get used to being like, well, not everybody's probably gonna like what I'm doing, but that's okay. And that's okay. That's okay. Well, like I said, you're doing great stuff.

[00:35:34] If people wanted to join the bandwagon and learn more about your association, where can they find it? UnitedPTA.org. We'll be updating our website within the next week or so to put all of our initiatives on there to show that what we're working on right now, coming forward. The website, I think, still has mostly initial launch stuff on it. Uh, we've really found our footing over the last few months, uh, found our place and what we're, we're good at. Oh, good. All right.

[00:36:01] And people can donate to the cause there as well for the administrative support and whatnot, especially if they're not APTA members, I'd highly encourage to take whatever you were going to spend on your APTA membership and throw it somewhere. Good. That's your. All the money for our association goes to whatever we're working on. Um, I started this association with my own money. I haven't taken a dime paid back yet of it. And, uh, it doesn't really matter to me. Uh, so everything that goes in will go out toward our small bills that we have each month

[00:36:30] for website and things like that. But other than that, it's all I have to see based, you know, well, you gotta be, you gotta pay lawyers and lobbyists. Yeah. We have to pay like, so I had PPR, our attorney, you know, not cheap. We had to pay for that. Um, all those different things, you know, flying to Louisiana, uh, to meet with an attorney general, you know, not to stay in a hotel a couple of nights and pay for my flight. So, um, those things are important, you know, but we use it all for advocacy. So, um, we're trying to, as we, as we get more and more members, the, the savings account

[00:36:58] builds and it'll allow us to do more with it. And I, you know, if I can get around to, I would like to form a pack that we can, things like that. There's different types of packs. I'm still trying to figure out which one we want to do. The APTA packs is connected. It means you have to be a member to donate, but we can do a non-connected pack where your patients, your mom and dad, your brothers, sisters could donate to a physical therapy pack. Um, we might do something like that in the future. Um, ask them so we can donate and support candidates that, that are pro physical therapy.

[00:37:27] That's great. And if people wanted to find you on the social medias, where would they go? Uh, uh, Facebook's where I post most of the time cause I'm older. Okay. The one I understand the best. I am trying to start a TikTok page, but I have to get my kids to help me with that. I'm not a TikTok. Um, so you can go to Facebook United physical therapy association. Just find us there. Fair amount of followers already. Uh, that's where I do most of my posting. Okay. As we grow, we can find more people to help with some of the social media aspects. I would love to leverage that. Um, I don't have so many hours in a day for me to do things.

[00:37:58] We leave it over for people to post stuff. We don't approve everything, but somebody has a good comment. Then we get discussion going. We'll, we'll, we'll post comments from other posts from other people to get the discussion going. Well, that's great. Well, cool, man. Thank you again for taking your time, Scott. It was good to catch up and see all the good work that you're doing on behalf of the industry. I really appreciate it. I appreciate it. So don't take my word for everything I say about the value proposition stuff. I think that's how it goes.

[00:38:22] But, um, in terms of, uh, of that, uh, CM, um, the CMMI value-based care, but, um, but yeah, I'm learning as I go and it's been, it's been a great journey and I appreciate your time here. Yeah. Thanks for your work, man. Thanks, Nathan. Bye. Thanks for listening to the Private Practice Owners Club. If you enjoyed this episode, would you mind doing us a huge favor and leaving a review? This helps us get the podcast out to more clinic owners to help them create greater freedom and profits so they can own their future.

[00:38:52] And visit our website, ppoclub.com to find more resources and connect with us. Bye. Bye. Bye. Bye. Bye.