The Real Economics Of Physical Therapy

Insurance might cover the visit, but is it covering the care?

In this episode, Dr. Mike Aguino breaks down what really happens behind the scenes of physical therapy clinics, from insurance reimbursements and burnout to why great patient outcomes often come down to education, movement, and accountability.

We also dive into the future of rehab, the gap between physical therapy and personal training, and what it takes to help people recover and perform at a higher level.

Have you ever felt rushed through a healthcare appointment?

Accountability is leverage.

#anthonyamen #accountabilityisleverage #physicaltherapy #healthcare #rehab

Transcript

Welcome And Why PT Business Matters

SPEAKER_00 0:00

What's up, everybody? Welcome back to the Anthony Amor Show. Today we have Mike Aguino on, Mr. Physical Therapist over here. That's what we're gonna call him going forward. But we're super excited to have you on. Thank you for taking time to come do this.

SPEAKER_01 0:13

Yeah, I I appreciate it. I'm excited. Um, looking forward to chatting.

SPEAKER_00 0:18

We have a lot to get through, and I just want to start with the business side of physical therapy.

Burnout From High Volume Clinics

SPEAKER_00 0:26

Sure. Because I know you're in a little bit of that transition, right? So you're working full-time. Yeah. Right? You're also working out of a 55 and older community. So you're working with them through insurance of that. Walk me through why you're currently doing both.

SPEAKER_01 0:44

Yeah, sure. So years back coming out of school, it was like 2016, uh, when I had graduated from Sony Brook, uh, I took a job in a typical outpatient PT clinic, large volume. Uh, and and honestly, by the two-year point, I was burnt out. You know, it was just too many patients. Uh, I felt like, you know, I wasn't giving them the time that they really needed because volume was just being pushed. And, you know, unfortunately in our field, that that tends to be, I don't want to say the standard, but it tends to be what's typically done mainly to cover an overhead, right? You know, more people more patients you see, uh, you know, greater volume, more reimbursement, and then you know, that's the kind of business side of it. Uh and that that really took a toll on me mentally. You know, there came a point where I was like, I don't feel like I'm utilizing my knowledge base to you know impart uh really purposeful treatment on patients because people are coming in every 10-15 minutes, you know. So um it just wasn't for me. And I had then transitioned to academia where I work full-time at Adelphi as a professor in exercise physiology. I had my master's in that. Uh, and that was more of my speed. It was a way to, you know, you talk about accountability, right? You know, a way to hold myself accountable to stay on top of the literature and be a well-prepared, knowledgeable practitioner. Uh, and then I was missing the clinical side, you know, I was still doing it on the side, and and uh, but it wasn't my way. Uh so uh I then decided let let me try to do something on my own here. Uh, and you know, an opportunity uh came up, and um that's why I kind of shifted toward this kind of a little bit of a part-time side business, a little bit of a hustle. Uh, but it was a nice way to try to put together a PT practice um that I've had envisioned in my mind where I work one-on-one with patients 45 minutes straight to an hour. Um I do accept insurance through Medicare, um, but uh the other part is cash-based. Uh and our field, again, unfortunately, because reimbursements drop, and you know, each year there's a small percentage of a drop in reimbursement, more practitioners are shifting toward a cash-based uh system. And you know, it's hard a lot of times for patients to accept wanting to pay out of pocket for services, especially when they pay for insurance. Um, but honestly, that it's one of the only ways that they're going to get one-on-one real attention. Uh, and you know, it's a little bit more out of pocket, but ultimately um, you know, practitioners that are going cash-based are are really spending every single second with the patient, and you don't see that a lot in in the healthcare system in general.

SPEAKER_00 3:54

I've been really looking forward to doing this episode because of that. Yeah. We've done a few on me talking about the financial side of physical therapy. We never really had a physical therapist to talk to. Right. So this is a good learning curve for those. So let's tie it together. What's your goal then? Right? Is your goal to leave Adelphi? No, to do it on your own?

SPEAKER_01 4:17

No, I I really enjoy being at Adelphi. It's uh uh a great, great position for me. I do research, I I teach, um, you know, I mentor students, so it's a nice position. And you know, my goal really is to, you know, maybe build the side business and maybe hire uh another PT that has a similar mindset uh that would be willing to you know help me build it a little bit more. Um right now. But you do want to grow on a side. Yeah, absolutely.

SPEAKER_00 4:48

Right? And that would that be a brick and mortar spot ideally?

SPEAKER_01 4:52

I would hope so. One day, yeah. That's kind of the lofty goal, you know, to have a brick and mortar and and you know, facilitate some sort of practice through a brick and mortar.

SPEAKER_00 5:02

And then going brick and mortar, let's just walk through opening the business,

Building A One On One Side Practice

SPEAKER_00 5:06

right? So you go ahead, you hire another physical therapist, or you're doing it a little bit in the beginning. You mentioned briefly about reimbursement rates when it comes to insurance. What does a typical reimbursement rate look like?

SPEAKER_01 5:20

You know, it really all depends on what's billed.

SPEAKER_00 5:24

Okay, so explain that in layman terms.

SPEAKER_01 5:26

Sure. So um depending on what's done in treatment, there are codes that are billed for, and the reimbursement per code is variable. Like you can bill manual therapy, therex, or uh neuromuscular re-education, and exercises and activities can fall under an array of different categories. Um the savvy practitioner is gonna bill specific codes because they get reimbursed a little bit higher. The other end is being conscious of making sure that you're accurately billing, right, for what services you're really rendering. Um so generally, you know, depending on the time that's spent, right? And and in theory, you bill for time with direct patient care, right? So that's that was my whole struggle with large volume. It's well, the direct patient care that I had was never really 45 minutes straight, right? But we're billing three units, you know, in other facilities, and you know, to me that didn't feel right. Um you know, I was there, I was present, I oversaw everything, so technically I guess it that's that happens. Uh but you know, now being one-on-one, I'm getting the three units in, and I get, you know, um, you know, whatever that range of of reimbursement is, which is like $75 to $90. Now that's variable depending on the facility. Like if we start talking about contracted agents, like bigger medical systems, you know, I'm not gonna name any, but you can think bigger hospital systems, they negotiate a different reimbursement, right? So uh they get paid a little bit more than you know the little guy like me, right? So it's tough. It's tough.

SPEAKER_00 7:22

We had growth pain management on. I made a very similar case. They're a smaller pain management clinic, but because they're not North Wales, Stony Brook, big name companies to negotiate their own rates, they get squeezed. Yeah. And these bigger companies get to pull more because they have direct negotiation power or lobbying power, right? Is another way to look at it, in order to get reimbursed more for it. Now you mentioned for 45 minutes you're gonna be between how much 75 and 90? Yeah, somewhere around there. So you're looking roughly 150 an hour if you break it out.

SPEAKER_01 7:55

Yeah, yeah. Um, that's accurate. And you know, an evaluation you get reimbursed a little bit more. Um and then there's a patient responsibility. So, you know, that 75 to 90 includes the patient copay or whatever their secondary insurance would ultimately cover.

SPEAKER_00 8:12

So, what does a typical patient copay look like?

SPEAKER_01 8:14

Variable, depends on what's what's uh billed for, but it can range anywhere from like $13 to $18. So it signs up to like $25. The eval is a little bit more.

SPEAKER_00 8:26

So max all in is $200 an hour?

SPEAKER_01 8:29

Uh not even. Not not no, not even. I think the $150 is accurate uh because that that $70 to $90 or the $100 that you get reimbursed, Medicare is paying $80, $20 is a patient's responsibility. Uh so one $150 would be accurate, I would say.

SPEAKER_00 8:49

How much do physical therapists two two questions because there's two answers to this. How much does the average physical therapist make? And how much do you think is fair for the average physical therapist to make?

SPEAKER_01 9:01

So the average PT uh I think now now uh they're coming out of school and making close to like $90,000 to $100,000 a year. Um sometimes a little more, depending on where they're working. Um and that's a big change from when I came out of school, you know, now 10 years ago, but huge change from 10 years ago, which the starting salary back then was around 65. Um really not a lot. Um and which is good. I'm glad that's it's transitioned and you know, PTs are making more. I I think um it's a profession that based on on the amount of money that you spend um on your education, it's not compensated for um on the back end. So your return on investment sometimes is not great. Um so PTs tend to hustle, you know.

SPEAKER_00 9:59

So you have to go, just to reiterate now, at least in New York State, bachelor's is a must. Bachelor's. You used to be a master's, now it's a doctorate. Correct. And you still have to get licensed to the state and pay for a licensing exam.

SPEAKER_01 10:13

Yes, yeah. So you pay for the licensing exam, and then every uh, I believe it's three years. I just renewed my license, but every you know, three years you have to renew your license.

SPEAKER_00 10:22

And because you're medical, you have to get my practice insurance.

SPEAKER_01 10:25

Yes. Which which isn't a whole lot of money in PT. It's it's about, I think I pay $180 for the year, you know. So not not a lot, but you know, uh, in comparison to other medical professions, it's signific you know, really low.

SPEAKER_00 10:39

So you're talking how long from bachelor's doctors, another four years?

SPEAKER_01 10:43

So bachelor four, you know, and then doctorate, you're you're doing three years. Three years. You're looking seven years plus schooling costs, right? Yeah, right, depending on where you go. You know,

Insurance Coding And Reimbursement Reality

SPEAKER_01 10:56

there's variability in in a lot of those those schools.

SPEAKER_00 10:59

On a student loan, you're paying five percent on, or to eight percent depending on the loan. Right, variable, right. Obviously, grad you're gonna pay a little more on. Right. You're not making any money.

SPEAKER_01 11:10

No, it's it's tough. It's tough, and that's why people work a couple jobs, you know, or they'll take the extra shift, you know, they'll try their best to to um you know, to try to make up for what the lack of uh return on investment is. And I mean, it's it's a really great profession, you know, and when you look at it from uh uh within the medical field, you know, you're one-on-one with patients. You spend, you know, out of all the practitioners in the medical world, we're the one of the few professions that spend a lot of time with patients. Even in that example I gave you of you know being in a busy clinic and at volume, volume, volume, I'm still probably spending more time with the patient in that scenario and in that environment comparison to other medical professions. Now, um, you know, uh you make a good point here, you know, it's it's unfortunately PTs are a little squeezed, and part of it comes from lack of reaction.

SPEAKER_00 12:09

Physically can't just to do the math for you, because we're the same industry. Physical air person training is the same type of model, right? Similar, yeah. Very, very close. At a hunt paying someone $100,000 a year, only pulling upwards of $175,000, $180 an hour, there's zero margin in that. It yeah, it's tight. Like you physically cannot run a business with that margin. No, no, and then so you don't have a choice but to go high volume.

SPEAKER_01 12:38

Right, which is unfortunately what's happened, and which is unfortunately why most insurance companies reduce their payment. You know, over the years, Medicare's allotted amount has has drastically reduced. Um, and and part of it, unfortunately, was back in the day, well before I was even maybe thinking about being a PT, it was like, yeah, you get PT services, they'll get paid for, and uh, but unfortunately, people took advantage of that. Uh, and now insurance companies obviously squeeze, you know, they there's a cap on how much PT is allotted. Uh, and and in some cases you have to fight and argue for medical necessity, and it it's it's challenging. Uh, and you know, it's twofold here. Part of it is tuition costs are very, very high, and I'm I'm speaking about that relative to you know where I am in my world from an academia standpoint, all across the country, it's really high. Um, and that puts students in general in a very difficult position. And then the opposite end, specific to PT, the since the reimbursement isn't great and you have to go larger volume, um, thankfully, you know, the starting salary has gone up, but um it's it's a tough position. And um, you know, it's a it's it's a shame because it's a really good profession. Um, there's extensive education uh that's involved, and when you compare it to, let's just say, a physician assistant who's making way more in terms of a starting salary, and the education is uh similar over the past few years, but previously less, it was only a two-year degree. Um it it um a lot of students have shifted toward wanting to go the PA route, you know, because of the return on investment. Um so it it's tough to see our field go through that at this point. Um I'm hoping things change.

SPEAKER_00 14:41

I mean one or two things is gonna happen. Because inflation is always gonna be a thing. So not only are you let's say you're getting reimbursed

PT Pay Versus Education Debt

SPEAKER_00 14:48

4% less, it's not really 4% less. You're losing 4% plus you're losing inflation 4% the other way, so you're really losing 8% annually.

SPEAKER_01 14:55

Right.

SPEAKER_00 14:56

That's a lot to keep stacking onto someone.

SPEAKER_01 14:59

Yeah.

SPEAKER_00 15:00

So two things are gonna happen. One, people are gonna stop becoming physical therapists. Yeah, you're gonna look at it and be like, well, this isn't worth it, right? Right. On top of that, you're you're gonna have to go private. Or because all the big companies that are negotiating the rates and getting fairly reimbursed are gonna keep swallowing up the little companies. Yeah. So you either go work for them, or you go private cash only, you cannot take insurance, you won't live, or you just don't go down the ride itself.

SPEAKER_01 15:30

Right. And you know that all sucks. Right. Yeah, absolutely. I mean, and that's what listen, those those big systems, they pay well, right? They they their salaries are are okay. Um when you look at now practitioners, like you said, they're shifting toward cash-based PT.

SPEAKER_00 15:48

You don't have a choice.

SPEAKER_01 15:49

Yeah, no, they don't. Um, and it's a hard sell, unfortunately, right? How are you gonna for for most people? I I pay for insurance. Okay, well, I pay for insurance that's gonna cover a medical cost. Why should I pay out of pocket for PT? And that's where you know, PTs that go cash-based, you have to be very good salesmen uh or saleswomen. Uh, but you know, you have to market yourself really well. And honestly, the cash-based PTs, in my opinion, are ones that are really thoughtful uh in their approach relative to patient care because they understand that patients are making a big investment choosing them, uh, which uh, you know, chiropractic services are very similar, right? Not a lot of not a lot of insurances cover chiropractic medicine. Uh so there it's kind of a similar boat there. Um so it's really interesting. Uh and like I said, I I love what I do. Um and it's tough to see the profession kind of where it's at right now. Um, you know, time will tell how what happens. But to your point, I mean it seems like there's you know, we'll see what it what the trend is like over the next few years, but you might start seeing students maybe not opting toward a career in PT and maybe other medical professions.

SPEAKER_00 17:14

The financial episode I ran between physical therapy and personal training, to give you an example, you don't start making, and I'm not gonna say making, I'm gonna say netting more because there's a difference between making and netting. So, what money do you actually bring home? More money than a personal trainer until you're 20. So as a personal trainer going into that field, which you could just be a trainer, right? There's really that much credentials to it. Right. You are gonna make more money than someone who has to get the bachelor's, a doctorate, be licensed, carry them out practice, and your your education is on a whole different level, all because you got squeezed out by insurance companies who are forcing you to do a specific thing. And there's two sides to it as well, and I want you to speak more plainly about it because I talk about it all the time, but I'm not a physical therapist. From my understanding, insurance companies also they have a doctor on their payroll, right? And that doctor is supposed to litigate for them in a sense about the patient's care, but what how many sessions they're allotted for physical therapy.

SPEAKER_01 18:17

Yeah, it depends on the insurance. Like there's uh there's usually a a physician or um um kind of uh a medical like overseer for an insurance company and they'll approve visits. That's variable from insurance company to insurance company. Uh and there's times, you know, that you have to get on the phone and say, you know, patient XYZ can, you know, has this is their medical history, right? Which plays a big role in outcomes. Um it's not just, you know, low back pain, it's low back pain coupled with the fact that this person is diabetic, has a history of depression, XYZ, you know, their rate of recoveries is inevitably going to be a little bit longer. Um, so you have to advocate for your patients. And you know, it's it's it's our job to do that. Um but it's time consuming, yeah, absolutely. You know, it's another part of the job. Um and yeah, I mean, it's it to your point. Someone, if we're looking at it from a dollar standpoint, I mean, yeah, I mean you can do be a personal trainer and not have that overhead of tuition and and do well for yourself. Um, but there might be uh a ceiling, right, with that as well. And same with PT. I mean, there might be a ceiling in that profession as well. It depends all on what you do. Um so uh it's it's tough. I I mean a personal trainer can open their own gym, right? No different than a PT could open their own PT practice. Um, scope of practice is obviously a little bit different, right? It really all depends on what you're interested and ultimately wanting to do. Um, I believe our field in PT really would benefit from more individuals emphasizing the importance of exercise and fitness. You know, personal trainers or having an exercise physiology background, I think makes uh a PT that much more, um, in my opinion. Uh it uh where our job is to teach people to be active, right? And you know, part of a course that I teach at Adelphi is for our phys ed students, you know, uh students that are interested in going to work in a school setting, and I say, my job is no different than your job. I said, and arguably your job is more important than mine because you're working with kids, trying to emphasize the importance of being physically active. And if you can break through and you know, show them that physical activity is such a big part of their life, uh, and it needs to be, and it doesn't have to be that they have to be the best athlete and whatever, they just need to be active, then honestly, you're gonna make my job way worse because they might not run into the same problems 20 years down the road, you know, 30 years down the road, 40 years down the road. So um a lot of these professions have a ton of overlap. Um I think that you know it all depends on on what you want to do. You know, I I I wouldn't I wouldn't downplay the PT profession by any means.

SPEAKER_00 21:34

I'm not trying to downplay it, I'm trying to be an advocate for your field.

SPEAKER_01 21:40

Oh, yeah. No, absolutely.

SPEAKER_00 21:42

Let me let me let me express a point because I got a lot of hate from posting that video on there. But people just don't understand. I feel bad for what's going on in your profession.

SPEAKER_01 21:50

Yeah, it's a difficult reality to swallow for for a lot of PTs, unfortunately.

SPEAKER_00 21:54

You're gonna end up doing our society a disservice by killing an industry that should be there. Because it was squeezed out by an insurance company. And I want to talk about your point of phys ed really briefly. Because I don't know if you know this. I went to Hostra for graduate school for two years to be a PE teacher. And I got to the shadowing part of it and was so disgusted with what was going on in schools of how they were teaching making what for the making PE that I bounced out and left. I was totally turned up because, yet again, some administrator got involved and killed the physical therapy was uh sorry, physical was. The same thing is happening to PTA because some administrative or insurance companies are squeezing you guys and saying it's your fault, it's your not. It's just a model they promised you this little golden ring and then pushed you out of it. And there needs to be a change, and that change has to start on an individual basis. Like, take it from a client standpoint, right? You should want to go hire a physical therapist out of pocket. Who gives a shit if your insurance covers it? Get worse insurance, pay less for it. Right. Because you're gonna get shit quality because you're gonna get 10-15 minutes, they're gonna send you off to PTA. They're like to an extent, almost don't have time or not allowed. And I that's a really gray air for me that maybe we can explain a little more. Like, if I hurt my knee, you can only work around the knee or you can't work the rest of the body. I don't know if that's insurance or if that's just time, but it's sucks because it doesn't give people that full approach. Plus, what from what I've heard from other physical therapists and talk about this too, so you have two points. Is if you work with, let's say, an athlete as an example, you can't get them back to the field ready. You can only get them to a certain extent ready, what's considered normal. Or for someone at 80-year-old,

Cash Based PT And Patient Advocacy

SPEAKER_00 23:47

not healthy 80, just normal, would it consider an 80-year-old bet to a certain extent. Talk about both those points a little more, yeah, and then pick up from there.

SPEAKER_01 23:54

So I'll start off with with your point about um your point about advocacy, right? You know, in our field, thankfully, we have like the American Physical Therapy Association, there's delicate assemblies where they go and advocate and lobby. And you know, they I know a lot of individuals from from New York. I served on on that New York chapter, Long Island chapter as well. And they go up to Albany and they they fight the good fight. But, you know, there needs to be more of that. Um, and um unfortunately a lot of PTs don't go and buy into having to go lobby because they don't have the time they're working, right? Um, or yeah, they feel like it's gonna fall on deaf ears, unfortunately. Um, so that that's one point. So your other point about not treating, you know, body parts, it is a gray area. I mean, um, you have to be able to make a link. I mean, to me, when I treat a patient, it's it's uh it you're treating the person, right? And when you're treating a person, you're treating their whole body. So you're coming in with knee pain, but let's talk about you, right? What's going on with you? Are you sleeping well? How are you eating? You know, it's a bit it's a full big picture, right? That's that's how care should be. And yeah, I'm treating your knee. We're gonna work on trying to reduce the pain in your knee, but the knee pain could be related to your ankle, could be related to your hip, could be related to your back. Um, so obviously it our body's all chained, and and you know, PT should see a patient as as one one big picture. Now, if there's knee pain, but you feel like you know there's something else going on in their back or their hip, and it needs further investigation, then that's a time obviously that we refer out uh and not necessarily take matters into our own hand if we think that there's something else going on. So I think that's kind of the gray area. I I know there are I'm sure there are places that say, no, your prescriptions for your knee, I'm only treating your knee. Um that's happened. I've heard it from patients.

SPEAKER_00 26:04

I've heard it from insurance companies.

SPEAKER_01 26:06

Yeah, well, it depends on what you code, right? Yeah. Um, and that's you have to put in a diagnosis code when a patient comes in. And um even if, let's say the script says back pain, and I've had this happen honestly a few times over the course of the past couple weeks, the script will say low back pain, or it'll say, you know, uh lumbar ridiculopathy, and it's clearly their hip, right? I have to put a diagnosis code as their back because that's what's provided on the prescription, but I also put a diagnosis code for their hip because I feel like, because it's I'm a medical professional too, right? And it's my medical opinion that this is not really stemming from their back, it's probably coming from their hip. And I put that diagnosis code in, and then it's a phone call to the physician saying, Hey, this is what I found. Um I'm not sure if you want to take another look or not, right? And I kind of leave it there and I document it, you know, that I had a discussion, I informed the patient, and uh everything is in writing there. Uh, and I treat them as a full person. And if I have to go and argue and advocate for the patient, I will, you know, it's just part of, I guess, the oath that that I took being a PT. And it's all about being a good person anyway. I mean, you you're you're the same way when it comes to personal training, right? Like you're gonna treat the person as a whole, right? They're gonna come in with goals and you listen to those goals, you understand them, you gear everything toward those goals. Um, but you're not just focusing on that, it's them. Um so to to that point, that gray area is I I think does exist, you know, uh, unfortunately, but um I I don't I don't stay in the gray. I kind of just you know treat the person as is. Um your second point, um, remind me.

SPEAKER_00 27:58

It was a they are allotted visits uh because they only want to get you back to what they think the actual.

SPEAKER_01 28:04

Oh, right, right, right. Yeah, that's that's tough because uh it's what

Treat The Whole Body Not A Body Part

SPEAKER_01 28:09

is what is quote unquote prior level function, right? That's that's what we're well. Are we getting the person to that point? What is that point for an athlete? That prior level of function is markedly different than, you know, uh, let's just say someone who's sedentary, right? I don't want to say older adult because some older adults are really, really active, right? Um, so prior level of function is really variable. Um and it's tough because then there comes a point where insurance won't cover any more visits, and then there should be, in theory, a transition into strength and conditioning. And you know, if we look at it from an athlete's perspective, and it's not there, or even even someone, let's just say that's sedentary, like there needs to be some sort of strength and conditioning progression back into day-to-day life. Um, and sometimes that that doesn't happen. In PT, obviously, we set goals, really objective goals, and you have to be realistic with those goals. And you know, sometimes it's being realistic within the confines of what's ultimately gonna be allotted for. Uh in some cases, you you're realistic with the person, regardless of what insurance is going to allot for for their visits, and I think that's a better strategy. Um but it brings me back to my point that sessions can't be wasted with people. Uh and and the emphasis on activity and exercise is so, so, so important. You know, I I'm a uh my students ever listen to this, they'll they'll laugh. But I the disbelief I have in heat packs, cold packs, electrical stimulation.

SPEAKER_00 29:55

I'm so glad you said that.

SPEAKER_01 29:57

It's um it's essentially a babysitter, right? I remember one of my professors calling it that.

SPEAKER_00 30:02

It was because they bill coating on heat and stem. Yeah, and it doesn't like it.

SPEAKER_01 30:06

And honestly, it doesn't reimburse well, you know, so it's a waste.

SPEAKER_00 30:11

Oh, it's five, ten dollars extra per person.

SPEAKER_01 30:13

And uh, you know, I don't do it, and if patients ask, I'm always like, you could do that at home. Your time with me is spent doing other things. And um, but you know, wasting visits, wasting time doing stuff like that, that that eats up, you know, a visit for that patient. And, you know, that's kind of part of the reason why the profession, I think, has fallen where it's fallen to, because if a patient comes in and they're limited, let's just say they've had uh, you know, uh AC joint reconstruction, they had some sort of surgery, they're limited in their range of motion that they they can achieve passively. If you're at that point on day one, you don't need to see them again until they're cleared to do more. Why see that person four or five times during a period of time where they're really limited in what they can do to allow surgical healing and normal biological healing to occur? Why not save those visits and bank those visits for later? And, you know, as we transition to trying to get someone back to their prior level of function, we have to think about I want to save these visits for when this person can do more, and I want to educate this person that they need to take their health into their own hands. So I want to see you once a week or once every other week. Here's your homework. Come back to me in two weeks and let's reassess.

SPEAKER_00 31:42

But then you're banking in the person doing that work, and I could tell you it's tough on my side. I get I actually get people that walk in the door. No joke, can't make this up. They go into physical therapy, they go, here's my at-home workouts. I haven't done a single one. I'm supposed to start this three weeks ago. All I want to do is just walk me through it. And I look at them and I go, I really appreciate you. Want us to do these six exercises? And we will, but we're gonna do a lot more than just these six exercises. Right. Because they lose that I kind of see you kind of need a blend of both, is my point. And I want to talk about something because I this good is a two-way street, and this is our problem with what's going on right now. Take personal training as a side, right? In New York State, specifically, and this isn't forever so bad, this isn't as far as you don't need anything to be a personal trainer. Yeah, no, you could literally be Joe Schmoe from the local deli, and Joe could be a personal trainer just because he works out and looks good. Right. And people are gonna follow him along because he works out and looks good, and then Joe Schmoe is gonna charge $250 an hour to work out with him, which is way more money than they would pay to go see a physical therapist out of pocket. Oh, yeah. So now what's gonna happen is they're gonna work with Joe Schmoe, they're gonna get hurt, they're gonna blow a knee, and then hand it back to you anyway. Right. So I'm sure you get a lot of people that work with trainers, quote unquote, and end up in physical therapy because they were hurt. And I know I actually knew someone, uh, that was his job. He would sue trainers. That was that's all he did for a living. He would be someone who is a professional speaker to sue personal trainers because of how bad it is in the industry.

SPEAKER_01 33:27

Yeah, it it it's how are we holding people accountable, right? So how do you find that blank? That's it, it's hard. Uh it it's very difficult too, because unfortunately, in this day and age, um anyone can go on social media and claim whatever the heck they want, right? And without adequate knowledge, you know, and not saying that most people don't know better, but it's exactly what you mentioned. It's the shock value, right? Of someone looks good, right? Oh, I'm gonna do exactly what they do or whatever they did, but that's not necessarily the right way, right? Or the safest way. Um, and it's it unfortunately is sometimes a marketing technique from from people. Um, and you know, it's it's difficult, it's challenging. And I think the only real way, um, at least from a personal, you know, and you maybe you could speak about it a little bit more, but from but with personal trainers, there needs to be better credentialing. I mean, and there needs to be more and more people are understanding, I think, the importance of being physically active. More and more people are gonna be seeking advice about activity and movement and exercise. Uh, so it's important that they're guided appropriately. Uh, and with that said, there's a lot of

Prior Level Function And Wasted Visits

SPEAKER_01 34:44

PTs out there, right? Because sometimes PTs are are getting referrals for you know reconditioning and you know, um, and you know, trying to improve strength. And some PTs, I I don't know if I'd let them work on conditioning, you know, my parents. So, you know, for example, like you know, they they don't have an exercise background, you know, and um it's about practicing, I think practicing a little bit about what you preach, you know. If you're in a movement industry, like it's important that you move, it's important that you're knowledgeable about it, it's important that you keep up with your you know, continuing education um and appreciate that you don't know everything, right? That's one of the difficult things or one thing I see with personal trainers, PTs. You don't know everything. I don't know everything. There's still a lot for me to learn, right? And once you can acknowledge that, uh, I think you do your patients a better, you you give them uh a better outlook uh about you and you understand and you appreciate that um you're there to help them, but also learn obviously um as you're going through their their care. Uh with most people that are online promoting that I'm gonna do this, this, and that, you're gonna lose fat, you're gonna gain lean mass and blah blah blah in this amount of time. Um it, you know, people buy it because it sounds good, it sounds easy, uh, and uh but there's no basis behind it. And um, part of it is because most of those people feel like they know the most, but they actually might not.

SPEAKER_00 36:24

Yeah, I mean uh that kind of ties in the summary of this, right? Where if I own a gym or I'm in a kind of fitness studio, right? And my patients or clients are your clients. Like my ideal person just got out of physical therapy and needs help going to that next step. That's my ideal person. But it's so hard to get trust a physical therapist to refer to us because one, they're bogged down and you're just seeing six patients in hours and have no time to refer. Or two, they just don't trust trainers because they look at the local big box gym and go, I don't want to send people to that. I mean, I had to have to, we had to self-select. Like that's what I do during COVID is created an apprenticeship program with the state of New York. It cost me 10 over $10,000 and years to get New York State to finally put at least some optional credentialing for trainers. And it's not there, it's live, we have it. So it means it's on the job training, at least it means it's a year of college, but then we gotta take it the next step even further, where because I know AI takes people's exams at this point, right? Online, so having an online certification is garbage. So we sit them down on our second round interview and give them a written test they have to pass on, and then go on the floor and do practical, and then we do annual exams, and then we do Thursday meetings, which you've been a part of and done, and then we do workshops. So they they have to be really freaking good. But that's our job, that's what we self-selected. There's no people don't know that. So we get caught up with the other bullshit that we do, and then physical therapists won't take us seriously because they assume we're with them. So it's how do you create a win-win scenario where we could have this streamline of referring to each other? We can have this streamline, people know it's I get surgery, I go to physical therapy. When I physical physical therapy, my program continues into a gym with a specific. How do you create that?

SPEAKER_01 38:30

You have to find like-minded minded people. That's what I mean. That's the only way. I mean, unfortunately, in every profession, you're gonna have different views, you know. There's I I have colleagues and and friends, you know, that our approach to treatment is markedly different, you know, like they're some are very heavy manual-based, you know, they they live and die and by manual therapy. I'm like on the other end, you know. I'm thinking movement activity, my less of my hands-on you is probably a little bit better for for most people. And there's a time and place for manual therapy, so I don't want to dismiss that. Um, but you have to find like-minded people, you know, you have to be in an environment where um, you know, a PT and a personal trainer are working closely with one another, you know. Like if your facility had a PT here, for example.

SPEAKER_00 39:19

You know what? You know, we're not allowed. You're not because New York State's scope of practice. If I in most states I'm allowed to hire a physical therapist, in New York City I'm not.

SPEAKER_01 39:29

Right. Well, I could see, I mean, you'd have to be under like a professional limited liability question.

SPEAKER_00 39:35

Which I'm not allowed to unless I have some kind of other professional that you have a licensed. I have to have MSO through that or a doctor owning, which is right, I'm looking to go anyway. But I'm not allowed to.

SPEAKER_01 39:47

Right.

SPEAKER_00 39:48

So now what we just put in this, like, what do we do?

SPEAKER_01 39:53

Yeah. Oh, you could you could rent the space to someone, no? Wouldn't you be able to do that? Wouldn't that be a way to do it?

SPEAKER_00 39:59

Because then you get into permitting issues because we're permitted differently, so the town looks at us differently. Gotcha.

SPEAKER_01 40:06

So it's

Trainer Standards And Referral Pathways

SPEAKER_01 40:07

Yeah, but I mean that would be the one way to bridge the gap, obviously, is you find like-minded PT personal trainer that they have the same values, same mindset, and it's a nice streamline. Um, but you know, I I I I think there'll always unfortunately be that gap. And I and I I see it sometimes even with PT relative to some of our c or some some physicians, right, that don't believe PT is really going to help their patient.

SPEAKER_00 40:36

Um they didn't have a choice after the opioid epidemic.

SPEAKER_01 40:40

Yeah, right. Well, and you know, that's that's part of it, right? And I mean the medical costs just in general for PT are much less than, you know, if pharmacological management or any surgical management or whatever it might be. Um But there are some physicians that don't believe PT is necessary for for their patients. Um and you know, that's just their belief. And it could be from a couple bad experiences, like you just don't really know. Um or there's physicians that just trust a handful of individuals. And uh you unfortunately, unfortunately get that. Um it I think that's a really good question that you pose. If that gap could be bridged, then obviously you get more people hopefully returning back to their activity. And that's part of our job in PT2 is understanding that how can we get them back not just to their prior level of function, but to their optimal function. Um and it's tough within the confines of obviously in you know limitations with insurance in some cases. Um, so yeah, it's tough, and there's a lot of overlap, you know, and there's a lot of PTs that are you know personal trainers or strength, you know, certified strength and conditioning specialists, and they use that, you know, to leverage themselves and and you know, try to get people to work with them, and I think that's a good thing. Um But you know, there's it's important that you find a good network of people that are like-minded and that you trust, you know, that you can then build a nice uh little pathway.

SPEAKER_00 42:17

Mike, I really appreciate it. I hope that you get we get two things out of this. One, the general public understands that even though your insurance pays for physical therapy, it's probably in your best interest to pay out of pocket.

SPEAKER_01 42:35

Probably, in in many cases.

SPEAKER_00 42:37

In many cases. The second side of this, I hope that maybe some kind of advocacy group will listen to this and push for you guys to make reimbursements rates go up instead of down. So you could get more people that want to become physical therapists, get more quality people in the programs, get more quality physical therapists out there because mom and pop business is the backbone of this country, and that includes physical therapy.

SPEAKER_01 43:01

Yeah, absolutely. You know, we've lost our way a little bit with that with these smaller clinics, and uh hopefully it makes uh cycles back, we'll

Accountability Question And Closing Ask

SPEAKER_01 43:10

see.

SPEAKER_00 43:10

So I'm gonna ask you the final question to ask everyone at the end of the show. Sure. It's all about taking accountability in your own life. What is something you would like to take accountable for right now that you have yet to take accountability for, especially when it comes to things we've talked about? Oof.

SPEAKER_01 43:27

That's a tough question. Um I don't know. That that that's a tough one. I'd have to sit and think about it, but right on the spot here, what would I like to take accountability for? Um that I haven't yet. So I'm gonna be a hundred percent honest here. So I'm accountable for my health, but I have not, which is shame on me. Alright, this is gonna be on you know YouTube and on your podcast here, but shame on me. I haven't been I haven't had a physical in in a very long time. And I'm probably due for one. And I I accept that I need to be better at at that and you know, maybe take my health. Um I do take my health seriously, but um maybe take strides toward that's the one thing that I would say I don't practice what I preach, right? So I tell my my patients, you know, go and follow up with your doctor, go get your blood work, you know, a few people these past few weeks, go to your cardiologist. You need you need to go follow up with your cardiologist, your heart rate response, your blood pressure response isn't normal to exercise. Um I I need to be I need to hold myself accountable and go follow up and get a physical. Um, so uh that would that would be the thing. That's a really good my wife's gonna hear that and she's gonna be like, I've been telling you this for months.

SPEAKER_00 45:01

You have to give a deadline to that. When are you gonna go?

SPEAKER_01 45:03

Um, you know what? I'll I'll make an appointment on Monday. All right, so I'll follow up with you and I'll tell you.

SPEAKER_00 45:08

So the time this episode comes out, it'll be past that Monday. Okay. So you need to post in the comments that you went and got your physical. Sure. Because you know what? It's hard for people to take you seriously who need them. You're right. Right?

SPEAKER_01 45:19

You're right.

SPEAKER_00 45:20

But we get so caught up in the day to day, we forget about ourselves. That's right. Mike, thank you so much for coming on. We got an awesome shirt for you because you took accountability. Awesome. So this is for you.

SPEAKER_01 45:30

I appreciate it. Thanks for having me. It was a great time.

SPEAKER_00 45:33

Guys, don't forget, like, subscribe, share, and please, if you found a physical therapist, thank them for going through all the years of schooling and pay it a pocket. Until next time.