Richard sits down with Steve DiPaola, the CEO of Empower Physical Therapy. Exploring challenges faced by the outpatient physical therapy sector in 2023 – from labor shortages to reimbursement issues and administrative burdens. Steve shares insights into how Empower PT has tackled these challenges, emphasizing agility and strategic approaches. As they reflect on the dynamic landscape of 2023, the conversation extends to predictions for 2024, foreseeing innovations and policy shifts.
Richard: Welcome back to Agile&Me, a physical therapy leadership podcast series. I am really excited to welcome Steve, Steve is the CEO of Empower Physical Therapy, a medium sized entity primarily based, if I'm correct, in the South Southwest of the US. However, I have got clinics in multiple places. Welcome, Steve. Thank you so much for being a guest today.
Steve: Yeah. Thank you, Richard. It's a pleasure to be here and always look forward to collaborating with our colleagues in private practice.
Richard: Absolutely. Before we start talking about 2023 you know how it's been for yourself and how it's been for the industry and then looking forward to 2024. I'd love it. Perhaps if you could just briefly describe your background. I know you're a PT and a very distinguished career. So, I'd love to know a little bit more, perhaps for the listeners.
Steve: Yeah, as you said, I am a physical therapist. I'm a Colorado native practiced early on in the Denver area in a variety of medium to large private practices. I then spent a fair amount of time at Physiotherapy Associates where I oversaw the Colorado region for a long time. So, I really appreciated my 17 years at physiotherapy associates. I then was CEO of PRN, based in Southern California for five years with the original founding owners there, and then in the last five years, I have kind of returned to private practice roots here, and I've been kind of the founding CEO of Empower Physical Therapy here based in Phoenix along the way. I was in academics. I taught at Regis University Physical Therapy program. I'm still on the board there and I was a regulator. I sat on the Colorado PT board for seven years until it became term limited, but private practice and PT clinical work is certainly who I am and what my DNA is.
Richard: A truly remarkable background. And thank you so much for taking the time today to be here. If we can just kick off with regards to 2023, it's been, what shall I say, an interesting year. Unfortunately, every year I seem to be saying that now. Change in healthcare is coming at us thick and fast and no sign of it slowing down. But with regards to 2023 in the outpatient physical therapy sector, what have you perhaps seen or experienced as it pertains to being the main challenges, would you say?
Steve: Yeah, I think I agree with you there wholeheartedly. I think it's every year. We kind of discuss our main challenges and I'll just say for all of us. I think it's been ongoing resilience that we learned and came out of the pandemic with certain things. And now I think every year we’re conditioned a bit to react to whatever the latest challenges are. So certainly, I think we're no different than anybody else in the industry. I would say, you know, the key drivers around the challenges have been, the labor situation with. A lot of folks leaving the profession and the tight labor market certainly stagnant reimbursement continues to be at the top of the list. It has been for many years. But I think now we're also seeing, you know, the increased admin burden around over regulation and, you know, just some things that really, I'll say, quell the joy of practice. And so, I think all of those sorts of things are creating a lot of challenges around why we all got into this profession and what comes along with treating patients. And then certainly as of late to macroeconomic conditions that have, you know, I've seen us battling inflationary pressures, not only in wage inflation, but overall operating expenses as well. So those are certainly all the challenges that I think we have at the top of the priority today, and that's just the top four, isn't it?
Richard: Yeah, I must admit you're weathering much better than me. I'm turning gray and losing that. So, kudos for how you're managing it. I'd love to unpack them individually, but perhaps an overall observation I have is labor, as you say, and challenges of, are really quite acute and reimbursement challenges. But it's really, whilst it's perhaps reached a critical level, it's been simmering and coming to a boil over a long period of time, isn't it? I think it's almost got to the point where, you know, dare I say it's boiled over, but it's been taking a long time, hasn't it? Is that something that you agree with?
Steve: Yeah, I do agree with that. I think both of you know, just the labor pressures that we have. And then just, I'll call it within our labor force, this job satisfaction, the burnout, the administrative burden. I think all of those are complementary factors that cause this simmering to boil over. Certainly, the pandemic created a tipping point there, but you're right. I mean, years and years of this kind of escalating around all of these competing challenges for all of our practices certainly led to where we're at today.
Richard: Yes, when I worked in hospitals a few years ago and, as a member of the American College of Healthcare Executives, they would survey leaders each year and try and identify what were the primary challenges and those primary challenges seemed to change each year. I’m getting the feeling that the challenge with labor is not going to go away. I think that's probably going to be a key challenge along with reimbursement really for the foreseeable future and I'm sure you've seen similar, the same statistics as it pertains to reductions in people applying for physical therapy school, the 10,000 that have still not come back therapists from COVID and the approximately 1000 to 1500 shortage of physical therapists every year from graduating classes compared to what we need. So back of the napkin math, I kind of calculated we'd be at least 20 percent shortfall nationally of therapists by 2029. So, I see this problem almost becoming worse certainly before it gets better. Unfortunately, I can't see it getting better in the immediate term. So, I see labor shortages as a critical piece, not only for 2023, but really, probably for at least the next five years. Would you agree?
Steve: Yeah, I would totally agree with that. I think we have this dichotomy here of this labor shortage that is going to continue into the future. I think we see not only the folks that left the profession, but, again, a new generation that maybe isn't, totally looking for a full-time full time gig we'll call it. I think a lot of folks are at a point where they can work to the level that they have to or that they want to versus what they have to. And then, like you, I agree. I think we know there's going to be a growing demand for physical therapy, and it's going to be faced by this shortage that we see that there is really no solution, whether it's on the academic side or otherwise. So, yeah, we're going to have to adapt and innovate, to really understand where we can go. And, and really, I think we have to be able to provide, you know, the services that the consumers and the public are looking for here. With the level of staffing that we have, I think it was always a luxury to have many resumes kind of sitting on the desk and our choice of folks. So, I think we have to create schedules and work profiles and things like that that work for our new young professionals and even our seasoned professionals and being very innovative and adaptable to how we can deliver the services where and when we can.
Richard: Yeah. So in a minute, I'd love to, to talk with you about what we're doing and what you're doing with regards to trying to recruit and retain with regards to that kind of idea of flexibility because 2024 and onwards, we're going to have to adjust how we think of labor and employees, but before we do that, obviously it's very easy to kind of get down on ourselves and the business as leaders, you know, we're in the trenches every day, but I think there's some been some positive things in 2023 that perhaps I either wasn't expecting or have matured and developed perhaps a little bit sooner. So, for instance, for myself, I think progress has been made particularly under the you know, WebPT's involvement with minority groups. I think advocacy seems to have got a lot stronger which is fantastic because it's been extremely weak for so long. You know, whilst there have been some economic headwinds, I think there's still been some positive things with volume, patient volumes being, I believe, pretty strong overall. So, are those the positive things that you've experienced and what else perhaps you've seen in 2023 that you know, is of the positive side rather than the king of the negative side?
Steve: Yeah. I think we always have to take a moment to reflect on what we bring to the industry, the healthcare industry. And so, my first point is, the patient's preference to seek what we have to offer them. You know, the ongoing momentum for what we bring to the health care system. I think all those things that we kind of revel in terms of accessibility and high cost, low cost, high value, high touch, personalized care. In this day of a mostly impersonal world here, I think we stand for something really unique and different. And we can't take for granted that people like to spend time with us. They trust us. They get that level of care that maybe is not so prevalent anymore. But to your earlier point, I'm proud of where the profession has gone in terms of our diversity and how we're trying to think about being, you know, more representative of the communities that we serve. I think we have in particular said that we know that even multi healthcare organizations like ours span different states. That every community is unique and different, and every corner is different. And we really strive. And I think PT in general is reflective of really what's delivered locally matches the communities that we're in. So, I'm proud of the profession because I think when we were young clinicians. We certainly didn't think that way, and we weren't profiled that way at all. So, I think advocacy is something that we got to get everybody doing, not a select few people or a few organizations. So, I think that's still a big opportunity for us to maybe get the 60 or 70 percent that kind of sit and watch what happens versus being part of having a voice in what should happen.
Richard: Yes, I know Chris Redding from USPTO talks about being the kind of the child in the corner and how it keeps having his lunch stolen. I talk about being the whip, the whipping boy or the profession being the boy that's been constantly whipped, but I do feel that at least we are advocating our value better or starting to, anecdotally, I hear of a lot of practices and organizations going to pay and say, you know what enough's enough. It's not acceptable to pay us 20, 30 percent less than what it actually costs us to provide the visit. We're done with it. And I think that's going to increase all being well. With the shortage of therapists, I see that the silver lining is with a shortage of therapists and more patients wanting our services. We're able to push back at these really abusive repayment reimbursement rates and say, look, this doesn't even cover the costs of the business. And, you know, if you truly believe a value therapy, which our patients do, then you've got to pay us at a rate that is fair and reasonable. And which hasn't been done for really from what I've seen for at least the last 10 years.
Steve: Yeah, I think it goes way back. And again, you're right. We've been rate takers, whatever we want to call ourselves. And so right with this year's planned Medicare cuts, right? It takes us to a 34 percent cut in a cumulative manner, which just can't sustain itself. And while we look at that, as you've talked about, some commercial payers are even more drastic in terms of their expectation of what we would accept there. And so, I think advocating to our peers is important for us to stand up for ourselves. But I also feel like we've got to have this organic ground swell in this wave to patients to understand if we do become more selective here that they're going to be on the outside looking in and also, you know, the key decision makers. So that should be the public that we have the privilege to serve every day. They continue to. be a consumer driven health care crowd. So, we hope that we'll get some support from the people that we're taking care of today. And then certainly the legislative people that have to answer to the constituents. I think they're starting to understand that while we have good, compelling data, why PT is the best option to your point. It's got to be valued. We can't just have a story there that doesn't attach the value. And the value is both in reimbursement and reducing this regulation and the burden upon us.
Richard: You bring up a really good point and when we're talking about 23 is this increasing administrative burden? Not only are we getting hit with relative and real reductions in reimbursement, but we seem to be hit all the time with additional administrative loads and I agree with you when we talk about burnout. I don't see the patient volume as that issue. I see the administrative burden, the issue. So, for instance, in England, I used to average 26 visits a day, which I'm very comfortable with. And the only reason I could do that is because the administrative burden was just, was so much less associated with it. And I think, whilst clinicians say, I'm struggling to see X number of patients. To me, I think that's really, I'm struggling with the amount of additional bureaucracy, non-value adding work that goes with seeing that patient. And you know, I would imagine your organization, like everyone else is trying to work out ways of at least trying to manage that administrative burden. What have you seen and what have you experienced in 2023 specific to the administrative burden and going forwards, what do you think perhaps we can do as leaders to at least try and, well, I don't know if controls are the right way, but at least try and, and manage it for our employees.
Steve: Yeah, I think you're exactly right here. Richard, we hear from our therapist every day that treating patients and maybe even in the current landscape of reimbursement, treating more patients is not an issue. It is what it takes to be able to treat those patients. So, you know, certainly the number one pain point is documentation time to document you know, the difficulty around it. And particularly when we think about creating access for new patients, again, one of the barriers is the time that it takes to produce an initial evaluation medical record. And so, we have taken that seriously because we think about all the things. What can we do? Certainly, there's the paperwork, the medical necessity reviews and the justification for care. And again, it's a double-edged sword. Not only are we being pushed with poor reimbursement, but the utilization management and the expectation to see people for a very short time, we'll call it a substandard episode and then expect a good outcome really kind of flies in the face of what we know is best practice. So, while we're trying to think about that, the number one point that we hear is documentation. So early on, we started with really kind of trying to create efficiencies through templating and suggesting best practices for people to have a better individual process and system. I'll just say that late in the last six months, we have taken on an internal project here to think about. Use of technology and AI here to create our own dictation documentation system that is not particular to any MR that we're using. It's homegrown. And our whole goal is to say. In my mind, you know, I'm 30 plus years into practice, like many others, what would make a difference in the life of a staff therapist? And it is not only reducing burnout burden, but like the joy of practice, like we should still love to do what we do. And I hear that from people every day, but they say, but here's the thing that I don't like. So, we're trying to create a path where people walk out. End of the day without dictation or not spending. I'm sorry. Documentation not spending time over the weekend because that is I think the tipping point where it bleeds into your family life and your inner personal satisfaction level. So, we're just running a pilot to see if we can do something that is not only time efficient but creates high quality and detailed notes as well. Because I think we've all learned that to use EMR efficiently, there's sometimes what's called note cloning or copy and pasting or those sort of things. So, we've really leaned heavily into trying to create a solution here internally for ourselves that will take that number one pain point away from, we'll call it the life of a staff therapist every day.
Richard: Yeah, I love it. I think technology is a differentiator and I think it can be extremely helpful. I would say there's two primary things between success and perhaps not failure, but certainly thriving versus existing. And one is the adoption of information or technology solutions, not just patient facing, but in all facets of the business. And then obviously the other is recruitment and retention and talking about, the administrative burden, my perception, and I, again, I could be completely left field here with payers, you know, their expectations of verification authorization reauthorization, plan of care, signing renewed plan of care post audit, pre-order, general standard reviews, special audits, et cetera, et cetera. All those things are. Blaring on the business and I believe you're turning off clinicians so by doing all these things as well as giving a what I believe is an abusive reimbursement rate by many large payers it is. Having an impact on the business down, but ultimately what that means is we're not going to be able to provide the services to those payer’s patients. So, it's really choking themselves off as a payer. Perhaps I'm being melodramatic. I don't know, but I certainly think that in the long run, they're, they're almost doing themselves a disservice with regards from the payer’s perspective.
Steve: Yeah, I think they're being short sighted and obviously for-profit health insurance, you know, sometimes doesn't make a whole lot of sense there. Again, if you follow again, the cost and the value and the ability for patients to avoid. not only more costly, more invasive, more potentially risky procedures, you think it would be like staring them in the face here, that this is the path and not only again, just some PT, because again, we know likely, one or two or three visits may not make a big difference, but of course, at PT, which we know the research supports is to really get to a good outcome to eliminate recidivism, but then you get penalized for utilization around what is best practice. To me, it's like, you know, doing half of a total knee instead of a full total knee and expect the same outcome. That's maybe a poor analogy, but I think that's what they're asking us to do. And then, we're on the hook for whether we deliver a good outcome and. You know, we're doing it on a hamstring basis here. So, I really think that, you know, there has to be some sort of understanding. I think we hear that when we produce this data and this information, and that's what I hope collaborations between you and I and our other leaders that, you know, have a voice and maybe have a larger footprint out there can really push that through and we can have the data from our systems that we're using To continue to push that forward and have people adopt that again, I know there's a lot of special agendas out there that are competing interests But at some point they should really say for the health and welfare of their patients to avoid unnecessary costs. I think that's got to be the big thing is what is the unnecessary cost. It's not just our service versus another service, but are we eliminating other unnecessary costs? And we'd like to think that logic prevails here. And I think we just have to keep at it. Telling the message, but back it up with data and good outcomes and really kind of work together in unison to push that message forward. Because I just don't think you know, you and I've been around long enough to think these commercial pairs will revert their methodology here. And just today, right? We're reading that maybe Cigna and Humana are going to merge, you know, that. It's even more paused. I think there's one, one group out there that was, you know, way larger than everybody else, but now we're heading towards, you know, multiple large groups that all kind of use the same offense. And to your point, if they have an awful lot of market share. And we should choose to. We just can't deliver the services. It's going to create a huge conflict for their patients. So, the patient loses, right? We're in this to give the patient a good clinical win and a good experience when but boy, it's getting harder and harder to do that.
Richard: I think the last thing you brought up with 23 was the macroeconomic environment and you know, those of us of similar age to you and I can remember high interest rates, but to be honest, a majority of people who are working for us and even our managers haven't experienced this type of macroeconomic environment and it’s been a struggle I'm sure your businesses has had to manage it like everyone else, and it hasn't been easy. We've seen some of the larger, a couple of the larger PT companies really get caught essentially with their pants down as a result of trying to manage the impact of both the interest rates and inflationary pressures. Have you found that the impact has been significant in 2023? And you know, in perhaps what way from a practical perspective, particularly from an operations perspective, how, how that's been felt.
Steve: Yeah, it's certainly been felt. I don't think anybody is void of that. So, yeah, I mean, obviously, the interest rates, you know, certainly have slowed down some folks' ability to continue to have good liquidity and certainly growth models. So, I think for us, we have tried to grow very slowly and very strategically as opposed to quickly and for a certain number. So, on that side, we've still been able to add really good likeminded partners to join us along the way. And so. We're, we're excited to continue to be able to do that because we're maybe not over our skis like some others, but I would say just in general, I'll say the inflationary pressures are really tough on the margins these days. I mean, certainly wage inflation is first and foremost, but you know, everything else that goes along with it, supplies and those sorts of things. And so, we think about, you know, what have been those. Those pressures and how might we be able to respond to them? And we know the point of care delivery is first and foremost. So, despite wage pressures and some of those sorts of things, we have to have really great clinicians that love what they do, and we've got to have. The support staff that are able to, to give, give a great experience and support that clinical delivery of care. What we know is most people still prefer and like that in clinic experience. So, we have challenged ourselves to think about the nonclinical cost management, right? The admin side and some of the other sides where we can maybe help reduce some of that overhead. Cost inflation here without jeopardizing the patient care and the patient experience. So, we've seen it all the way around. And so, we're just trying to think about how we might respond in some sort of innovative way again with technology with, you know, alternative labor forces, things like that.
Richard: Yeah, I think culturally, you know, your organization and mine are very, very similar with regards to the approach. I often call you know, talk about the tortoise and the hare. I'm very happy being the tortoise because eventually, ultimately the tortoise wins. Yep. And I'm still obviously, in the race that I think the tortoises have made great progress in the last 18 months where perhaps some of those pairs have struggled a little bit and are taking a breather. But anyway, moving on to 2024 I'm really excited for it in many ways. I am apprehensive. I'm not going to get me wrong. But you know, with patient demand high and increasing the clinicians that are being trained academically are very good. You know, when I compare myself, my level of academic training compared to theirs, you know, theirs is much stronger. Perhaps their expectations of the profession might not be quite the same, but you know, that's perhaps another topic for a different podcast. Inflation seems to be at least coming under control, perhaps I'll touch wood as I say that. So, 2023 from a visit volume perspective, I think was robust for many of us. So, what do you, what do you think, what are you thinking about, how do you think of 2024 perhaps for private practices and outpatient physical therapy?
Steve: Yeah, I think like you, I continue to be really encouraged about the patient demand and that, the consumer choosing us, more and more so directly. So, I love the fact that direct access continues to grow in the space, and that's likely where we should be and not just waiting for somebody to send us a referral. And even in places that have recently gotten direct access. I see many of our colleagues really embracing that and thinking about themselves as a direct musculoskeletal provider here. So that is certainly a place of optimism for me. And I would say like you, right? We see the inflationary pressures easing a little bit. I would even say in the last couple of months, I've even seen the labor issue ease just a little bit, too. So again, it continues to make me hopeful. I think again, what I really love to see is we do have some really engaged new young professionals. That is what fills the tank, right? We want them to be clinically excellent. We want them to have great things. Patient rapport skills and then demonstrate that value every day because we have to continue to fight the battle for the future of outpatient and private practice. And so, you know, I think we have to understand that the care we give to people is beyond our treatments. And so sometimes I think in the past generations, we were kind of hung up on our technical proficiency. And I think we know that in this consumer driven healthcare world, that the care that we give is inclusive of the experience and the trust factor. And that is unique to our setting. That's what I really feel like, like every private practice on every corner has had that rapport with patients that leads to high trust. And so ultimately what I want is our new young providers that are not on that burnout track. And I think we also see to be engaged right to something. And so, engagement, I always think about our purpose. Why did we become therapists to our people, which is our local team and maybe our broad organization? That just continues to have the passion to bring what we have to offer to folks, I think, is really great. Certainly. We need to continue to tackle the reimbursement, the regulatory issues, the advocacy around all those sort of things. But ultimately, I think it starts and ends with a really great clinical experience for patients and, you know, really demonstrating that we have the value and again, value is in the eyes of the stakeholders. But for patients, it is the trust factor that we get them to a good functional outcome. And that more people want to do this. I think we did this right? While the applicants to PT school have gone down and continue to do so. It's still pretty. It's still pretty strong. Again, I was ironically on a board call for the institution that I used to be involved with. I'm still on the board there. And so, the number has come down historically, maybe too. From 750 to around 625 for a class of 60 or 80. So, you know, there's still plenty of people that want to do that. And I talked to young people that are not yet in PT school, and it still seems to be a relatively sought out profession. So again, we can also look at the U.S. News and World Report that says. PT Is the 10 best job overall 10th best and in health care, it’s number three. So, if you are going to be fighting this battle in health care, we know that what we have to appreciate with patients is really unique and different. So, I'm an eternal optimist around private practice and feel like, you know, our young professionals that come in that we see every year. They have that drive and what we hope to do is not let them go down the path of disengagement by all of these other challenges that we talk about that we can keep people engaged for PT and, continue to see them go along a career that is satisfying, both personally and professionally.
Richard: Yeah, no, I think that's a great point when we talk about employees. I think that it's the first time where there's, I think, five different groups of generations in the workforce. Yeah. And certainly, I feel, I definitely feel one of the older generations now. And I struggle a little bit with trying to understand the younger generation. I assume it's just getting old. I will try my best. Don't get me wrong. But you know how I manage and lead my team has definitely changed. And it's continually changing how I managed 20 years ago would just be a complete failure. Now the expectations I have have had to be adjusted. And I think 2024 I'm going to have to continue to adjust those expectations considerably, to an environment that perhaps has different types of values and also flexibility. And I'm sure you're already doing a lot of things as an organization to address that. So, I'd love to know your thoughts about 2024 and beyond. And what type of work environment do we need to provide to our team members, employees, employees?
Steve: Yeah, I think we really need to find what kind of calls to them. And so, when we think about engagement, there's the Gallup definition or many others that I think, but I love to revert, to not only being physically present, but psychologically committed to the purpose. And certainly, our purpose first is being a PT. And then it is, I think about the people first mentality. We grew up in the generation of strong work ethic and always put the patient first, the customers, right. All of those slogans, but I think we've come to find that. Each individual has to be in a good place themselves, and they have to be not only supported by their team, but willing to support the rest of their team. So, I think we've really come to believe that we have to be in a good place ourselves as providers. To be able to put patients first because if we're not in a good place and we read about the mental health impact and the burnout, the stress, the job satisfaction. So, I think we revert back to, you know, how are we doing? We still certainly need to keep clinics open necessary hours, necessary days. So, it's not something that we say, hey, go work from home and do this. But I think there is an openness to making sure that we're meeting people where they're at, understanding what they're looking for, as long as it's reasonable about what the business needs, then we've been open to that. But I think we really have thought about this people's 1st mentality before we can get to putting the patients 1st. And so, again, we want people to have not just a work ethic, I think that's put your head down and do it. We would love for them to have some fun and have some joy and be connected to both their patients and their teams. Because you know, that's the long run to your point of the tortoise and hare. Another place is we want them to have good. Professional growth, both clinically and personally, and we just try to put people on a path that way. I don't think there's any one characteristic, but the new generation is different, and we've got to just understand that their values are something we have to become familiar with and adapt to as well.
Richard: Yes. You know, with the different generations, it's not as if there's a good or bad generation, it's just different, isn't it? In fact, in some ways, I would probably say the younger generation is probably much more healthy in their approach to life than perhaps I've had with regards to the kind of, put your head down, work for a company for 30 years. You get your service in, you're loyal to that business and, and you do whatever it takes for that business. And, and oftentimes, unfortunately, compromising one's own kind of other components of life. So yeah, the times against us a little bit. Do you have any other thoughts with regards to 2024, as you look into that crystal ball as it pertains to what to expect, anticipate or challenges or even opportunities?
Steve: Yeah, I think again, the challenges will be ones that are familiar to us. So, I would hope we're kind of adapting with an offense that is responding appropriately to those sorts of things. Again, you know, how we run our businesses are relatively the same, right? We want patients that we want providers. So, it always starts with that. And then we have to be strategic about how we can innovate going forward, whether it is, trying to streamline our administrative costs. I think that's probably a unique opportunity here. But I think that requires a mentality of not just doing it how we did 5 years ago and 10 years ago, things like that, both with you know, labor solutions, technology solutions. We need a therapist. We need patients. So, we have to build our business around that. And so, I would say that. You know, again, we hope with repetition, some of these, some of these fights that we have are these challenges be it reimbursement and regulation and admin burden that we can't, we can't take our foot off the gas. We have to continue to get more people with more voices and really, I'm a full believer that we got to use our patient base as our legion of raving fans to talk, to talk, tell the story, be willing to, you know, send a note to their legislator and make a call. Use some level of influence and then hopefully again, some at some point we know the insurance plans kind of have their offense. So, employers, I think, are starting to think about where we fit into the model and hopefully, they'll have a position of strength too, because those are the folks that are funding an awful lot of these benefit plans. And we've, we've kind of seen some of the work in the PT first model. The conservative care model. So hopefully again you know, the employers will also start to adopt some of this, but I would say that some of the industry challenges are not unique and different save some of them. Strong labor pressures, the other things we've been managing. And so, I hope that you know, some of the macroeconomic things will continue in the direction that we're seeing now. That will take a little bit of pressure off margins. And then we just have to continue to say that our earlier point is, if we can reduce enough of that admin burden, maybe to see. One or two or three more patients a day is what we need to do. We don't want to get to where we have to see, to your point, when we were young clinicians, north of 20 or 25 a day, that just isn't going to go. But, you know, if it can be a couple of more, we can keep the economics supported, then it's just a matter of what's that day-to-day life for our therapist. And are we supporting them both personally and professionally?
Richard: Before we finish what's been, I think, a great conversation in regard to summing up 2023 and looking at 2024 and beyond I always ask for perhaps whether there's any words of wisdom for our listeners?
Steve: Yeah, I would just say not to be afraid to enact some change. We know change is inevitable. We don't all love that. But I think if we're hesitant to change or innovation or technology or some alternative processes here that we've touched on briefly today. I, I just think we'll be on the outside looking in. So again, we're all facing the same things as an industry. While we want some of these wins that we need badly, we can't like to sit back and wait for that to happen. So not to be afraid to take some advice from friends or colleagues or other people that have done things in a different way. And I would just say our public is really seeing this innovation and change all before us, how business is being delivered, whether it's e-commerce or you know, we attach that to digital or self-service models from the admin side, all those sorts of things our public is ready for. And so partly we can maybe become a little more innovative from how we delivered care and. Provided a business experience from the last 10 or 15 years, so not to be afraid of trying some of those things that's right for you and your practice and where the opportunities may lie in your communities.
Richard: Again, thank you so much for your time today, Steve. It's been great chatting with you, and I look forward to listening to the podcast, not only in the next week or two, but actually in a year's time to see what's actually transpired. So, so thank you. I really appreciate your time.
Steve: Thank you, Richard.
Podcast Transcript
Richard: Welcome back to Agile&Me, a physical therapy leadership podcast series. I am really excited to welcome Steve, Steve is the CEO of Empower Physical Therapy, a medium sized entity primarily based, if I'm correct, in the South Southwest of the US. However, I have got clinics in multiple places. Welcome, Steve. Thank you so much for being a guest today.
Steve: Yeah. Thank you, Richard. It's a pleasure to be here and always look forward to collaborating with our colleagues in private practice.
Richard: Absolutely. Before we start talking about 2023 you know how it's been for yourself and how it's been for the industry and then looking forward to 2024. I'd love it. Perhaps if you could just briefly describe your background. I know you're a PT and a very distinguished career. So, I'd love to know a little bit more, perhaps for the listeners.
Steve: Yeah, as you said, I am a physical therapist. I'm a Colorado native practiced early on in the Denver area in a variety of medium to large private practices. I then spent a fair amount of time at Physiotherapy Associates where I oversaw the Colorado region for a long time. So, I really appreciated my 17 years at physiotherapy associates. I then was CEO of PRN, based in Southern California for five years with the original founding owners there, and then in the last five years, I have kind of returned to private practice roots here, and I've been kind of the founding CEO of Empower Physical Therapy here based in Phoenix along the way. I was in academics. I taught at Regis University Physical Therapy program. I'm still on the board there and I was a regulator. I sat on the Colorado PT board for seven years until it became term limited, but private practice and PT clinical work is certainly who I am and what my DNA is.
Richard: A truly remarkable background. And thank you so much for taking the time today to be here. If we can just kick off with regards to 2023, it's been, what shall I say, an interesting year. Unfortunately, every year I seem to be saying that now. Change in healthcare is coming at us thick and fast and no sign of it slowing down. But with regards to 2023 in the outpatient physical therapy sector, what have you perhaps seen or experienced as it pertains to being the main challenges, would you say?
Steve: Yeah, I think I agree with you there wholeheartedly. I think it's every year. We kind of discuss our main challenges and I'll just say for all of us. I think it's been ongoing resilience that we learned and came out of the pandemic with certain things. And now I think every year we’re conditioned a bit to react to whatever the latest challenges are. So certainly, I think we're no different than anybody else in the industry. I would say, you know, the key drivers around the challenges have been, the labor situation with. A lot of folks leaving the profession and the tight labor market certainly stagnant reimbursement continues to be at the top of the list. It has been for many years. But I think now we're also seeing, you know, the increased admin burden around over regulation and, you know, just some things that really, I'll say, quell the joy of practice. And so, I think all of those sorts of things are creating a lot of challenges around why we all got into this profession and what comes along with treating patients. And then certainly as of late to macroeconomic conditions that have, you know, I've seen us battling inflationary pressures, not only in wage inflation, but overall operating expenses as well. So those are certainly all the challenges that I think we have at the top of the priority today, and that's just the top four, isn't it?
Richard: Yeah, I must admit you're weathering much better than me. I'm turning gray and losing that. So, kudos for how you're managing it. I'd love to unpack them individually, but perhaps an overall observation I have is labor, as you say, and challenges of, are really quite acute and reimbursement challenges. But it's really, whilst it's perhaps reached a critical level, it's been simmering and coming to a boil over a long period of time, isn't it? I think it's almost got to the point where, you know, dare I say it's boiled over, but it's been taking a long time, hasn't it? Is that something that you agree with?
Steve: Yeah, I do agree with that. I think both of you know, just the labor pressures that we have. And then just, I'll call it within our labor force, this job satisfaction, the burnout, the administrative burden. I think all of those are complementary factors that cause this simmering to boil over. Certainly, the pandemic created a tipping point there, but you're right. I mean, years and years of this kind of escalating around all of these competing challenges for all of our practices certainly led to where we're at today.
Richard: Yes, when I worked in hospitals a few years ago and, as a member of the American College of Healthcare Executives, they would survey leaders each year and try and identify what were the primary challenges and those primary challenges seemed to change each year. I’m getting the feeling that the challenge with labor is not going to go away. I think that's probably going to be a key challenge along with reimbursement really for the foreseeable future and I'm sure you've seen similar, the same statistics as it pertains to reductions in people applying for physical therapy school, the 10,000 that have still not come back therapists from COVID and the approximately 1000 to 1500 shortage of physical therapists every year from graduating classes compared to what we need. So back of the napkin math, I kind of calculated we'd be at least 20 percent shortfall nationally of therapists by 2029. So, I see this problem almost becoming worse certainly before it gets better. Unfortunately, I can't see it getting better in the immediate term. So, I see labor shortages as a critical piece, not only for 2023, but really, probably for at least the next five years. Would you agree?
Steve: Yeah, I would totally agree with that. I think we have this dichotomy here of this labor shortage that is going to continue into the future. I think we see not only the folks that left the profession, but, again, a new generation that maybe isn't, totally looking for a full-time full time gig we'll call it. I think a lot of folks are at a point where they can work to the level that they have to or that they want to versus what they have to. And then, like you, I agree. I think we know there's going to be a growing demand for physical therapy, and it's going to be faced by this shortage that we see that there is really no solution, whether it's on the academic side or otherwise. So, yeah, we're going to have to adapt and innovate, to really understand where we can go. And, and really, I think we have to be able to provide, you know, the services that the consumers and the public are looking for here. With the level of staffing that we have, I think it was always a luxury to have many resumes kind of sitting on the desk and our choice of folks. So, I think we have to create schedules and work profiles and things like that that work for our new young professionals and even our seasoned professionals and being very innovative and adaptable to how we can deliver the services where and when we can.
Richard: Yeah. So in a minute, I'd love to, to talk with you about what we're doing and what you're doing with regards to trying to recruit and retain with regards to that kind of idea of flexibility because 2024 and onwards, we're going to have to adjust how we think of labor and employees, but before we do that, obviously it's very easy to kind of get down on ourselves and the business as leaders, you know, we're in the trenches every day, but I think there's some been some positive things in 2023 that perhaps I either wasn't expecting or have matured and developed perhaps a little bit sooner. So, for instance, for myself, I think progress has been made particularly under the you know, WebPT's involvement with minority groups. I think advocacy seems to have got a lot stronger which is fantastic because it's been extremely weak for so long. You know, whilst there have been some economic headwinds, I think there's still been some positive things with volume, patient volumes being, I believe, pretty strong overall. So, are those the positive things that you've experienced and what else perhaps you've seen in 2023 that you know, is of the positive side rather than the king of the negative side?
Steve: Yeah. I think we always have to take a moment to reflect on what we bring to the industry, the healthcare industry. And so, my first point is, the patient's preference to seek what we have to offer them. You know, the ongoing momentum for what we bring to the health care system. I think all those things that we kind of revel in terms of accessibility and high cost, low cost, high value, high touch, personalized care. In this day of a mostly impersonal world here, I think we stand for something really unique and different. And we can't take for granted that people like to spend time with us. They trust us. They get that level of care that maybe is not so prevalent anymore. But to your earlier point, I'm proud of where the profession has gone in terms of our diversity and how we're trying to think about being, you know, more representative of the communities that we serve. I think we have in particular said that we know that even multi healthcare organizations like ours span different states. That every community is unique and different, and every corner is different. And we really strive. And I think PT in general is reflective of really what's delivered locally matches the communities that we're in. So, I'm proud of the profession because I think when we were young clinicians. We certainly didn't think that way, and we weren't profiled that way at all. So, I think advocacy is something that we got to get everybody doing, not a select few people or a few organizations. So, I think that's still a big opportunity for us to maybe get the 60 or 70 percent that kind of sit and watch what happens versus being part of having a voice in what should happen.
Richard: Yes, I know Chris Redding from USPTO talks about being the kind of the child in the corner and how it keeps having his lunch stolen. I talk about being the whip, the whipping boy or the profession being the boy that's been constantly whipped, but I do feel that at least we are advocating our value better or starting to, anecdotally, I hear of a lot of practices and organizations going to pay and say, you know what enough's enough. It's not acceptable to pay us 20, 30 percent less than what it actually costs us to provide the visit. We're done with it. And I think that's going to increase all being well. With the shortage of therapists, I see that the silver lining is with a shortage of therapists and more patients wanting our services. We're able to push back at these really abusive repayment reimbursement rates and say, look, this doesn't even cover the costs of the business. And, you know, if you truly believe a value therapy, which our patients do, then you've got to pay us at a rate that is fair and reasonable. And which hasn't been done for really from what I've seen for at least the last 10 years.
Steve: Yeah, I think it goes way back. And again, you're right. We've been rate takers, whatever we want to call ourselves. And so right with this year's planned Medicare cuts, right? It takes us to a 34 percent cut in a cumulative manner, which just can't sustain itself. And while we look at that, as you've talked about, some commercial payers are even more drastic in terms of their expectation of what we would accept there. And so, I think advocating to our peers is important for us to stand up for ourselves. But I also feel like we've got to have this organic ground swell in this wave to patients to understand if we do become more selective here that they're going to be on the outside looking in and also, you know, the key decision makers. So that should be the public that we have the privilege to serve every day. They continue to. be a consumer driven health care crowd. So, we hope that we'll get some support from the people that we're taking care of today. And then certainly the legislative people that have to answer to the constituents. I think they're starting to understand that while we have good, compelling data, why PT is the best option to your point. It's got to be valued. We can't just have a story there that doesn't attach the value. And the value is both in reimbursement and reducing this regulation and the burden upon us.
Richard: You bring up a really good point and when we're talking about 23 is this increasing administrative burden? Not only are we getting hit with relative and real reductions in reimbursement, but we seem to be hit all the time with additional administrative loads and I agree with you when we talk about burnout. I don't see the patient volume as that issue. I see the administrative burden, the issue. So, for instance, in England, I used to average 26 visits a day, which I'm very comfortable with. And the only reason I could do that is because the administrative burden was just, was so much less associated with it. And I think, whilst clinicians say, I'm struggling to see X number of patients. To me, I think that's really, I'm struggling with the amount of additional bureaucracy, non-value adding work that goes with seeing that patient. And you know, I would imagine your organization, like everyone else is trying to work out ways of at least trying to manage that administrative burden. What have you seen and what have you experienced in 2023 specific to the administrative burden and going forwards, what do you think perhaps we can do as leaders to at least try and, well, I don't know if controls are the right way, but at least try and, and manage it for our employees.
Steve: Yeah, I think you're exactly right here. Richard, we hear from our therapist every day that treating patients and maybe even in the current landscape of reimbursement, treating more patients is not an issue. It is what it takes to be able to treat those patients. So, you know, certainly the number one pain point is documentation time to document you know, the difficulty around it. And particularly when we think about creating access for new patients, again, one of the barriers is the time that it takes to produce an initial evaluation medical record. And so, we have taken that seriously because we think about all the things. What can we do? Certainly, there's the paperwork, the medical necessity reviews and the justification for care. And again, it's a double-edged sword. Not only are we being pushed with poor reimbursement, but the utilization management and the expectation to see people for a very short time, we'll call it a substandard episode and then expect a good outcome really kind of flies in the face of what we know is best practice. So, while we're trying to think about that, the number one point that we hear is documentation. So early on, we started with really kind of trying to create efficiencies through templating and suggesting best practices for people to have a better individual process and system. I'll just say that late in the last six months, we have taken on an internal project here to think about. Use of technology and AI here to create our own dictation documentation system that is not particular to any MR that we're using. It's homegrown. And our whole goal is to say. In my mind, you know, I'm 30 plus years into practice, like many others, what would make a difference in the life of a staff therapist? And it is not only reducing burnout burden, but like the joy of practice, like we should still love to do what we do. And I hear that from people every day, but they say, but here's the thing that I don't like. So, we're trying to create a path where people walk out. End of the day without dictation or not spending. I'm sorry. Documentation not spending time over the weekend because that is I think the tipping point where it bleeds into your family life and your inner personal satisfaction level. So, we're just running a pilot to see if we can do something that is not only time efficient but creates high quality and detailed notes as well. Because I think we've all learned that to use EMR efficiently, there's sometimes what's called note cloning or copy and pasting or those sort of things. So, we've really leaned heavily into trying to create a solution here internally for ourselves that will take that number one pain point away from, we'll call it the life of a staff therapist every day.
Richard: Yeah, I love it. I think technology is a differentiator and I think it can be extremely helpful. I would say there's two primary things between success and perhaps not failure, but certainly thriving versus existing. And one is the adoption of information or technology solutions, not just patient facing, but in all facets of the business. And then obviously the other is recruitment and retention and talking about, the administrative burden, my perception, and I, again, I could be completely left field here with payers, you know, their expectations of verification authorization reauthorization, plan of care, signing renewed plan of care post audit, pre-order, general standard reviews, special audits, et cetera, et cetera. All those things are. Blaring on the business and I believe you're turning off clinicians so by doing all these things as well as giving a what I believe is an abusive reimbursement rate by many large payers it is. Having an impact on the business down, but ultimately what that means is we're not going to be able to provide the services to those payer’s patients. So, it's really choking themselves off as a payer. Perhaps I'm being melodramatic. I don't know, but I certainly think that in the long run, they're, they're almost doing themselves a disservice with regards from the payer’s perspective.
Steve: Yeah, I think they're being short sighted and obviously for-profit health insurance, you know, sometimes doesn't make a whole lot of sense there. Again, if you follow again, the cost and the value and the ability for patients to avoid. not only more costly, more invasive, more potentially risky procedures, you think it would be like staring them in the face here, that this is the path and not only again, just some PT, because again, we know likely, one or two or three visits may not make a big difference, but of course, at PT, which we know the research supports is to really get to a good outcome to eliminate recidivism, but then you get penalized for utilization around what is best practice. To me, it's like, you know, doing half of a total knee instead of a full total knee and expect the same outcome. That's maybe a poor analogy, but I think that's what they're asking us to do. And then, we're on the hook for whether we deliver a good outcome and. You know, we're doing it on a hamstring basis here. So, I really think that, you know, there has to be some sort of understanding. I think we hear that when we produce this data and this information, and that's what I hope collaborations between you and I and our other leaders that, you know, have a voice and maybe have a larger footprint out there can really push that through and we can have the data from our systems that we're using To continue to push that forward and have people adopt that again, I know there's a lot of special agendas out there that are competing interests But at some point they should really say for the health and welfare of their patients to avoid unnecessary costs. I think that's got to be the big thing is what is the unnecessary cost. It's not just our service versus another service, but are we eliminating other unnecessary costs? And we'd like to think that logic prevails here. And I think we just have to keep at it. Telling the message, but back it up with data and good outcomes and really kind of work together in unison to push that message forward. Because I just don't think you know, you and I've been around long enough to think these commercial pairs will revert their methodology here. And just today, right? We're reading that maybe Cigna and Humana are going to merge, you know, that. It's even more paused. I think there's one, one group out there that was, you know, way larger than everybody else, but now we're heading towards, you know, multiple large groups that all kind of use the same offense. And to your point, if they have an awful lot of market share. And we should choose to. We just can't deliver the services. It's going to create a huge conflict for their patients. So, the patient loses, right? We're in this to give the patient a good clinical win and a good experience when but boy, it's getting harder and harder to do that.
Richard: I think the last thing you brought up with 23 was the macroeconomic environment and you know, those of us of similar age to you and I can remember high interest rates, but to be honest, a majority of people who are working for us and even our managers haven't experienced this type of macroeconomic environment and it’s been a struggle I'm sure your businesses has had to manage it like everyone else, and it hasn't been easy. We've seen some of the larger, a couple of the larger PT companies really get caught essentially with their pants down as a result of trying to manage the impact of both the interest rates and inflationary pressures. Have you found that the impact has been significant in 2023? And you know, in perhaps what way from a practical perspective, particularly from an operations perspective, how, how that's been felt.
Steve: Yeah, it's certainly been felt. I don't think anybody is void of that. So, yeah, I mean, obviously, the interest rates, you know, certainly have slowed down some folks' ability to continue to have good liquidity and certainly growth models. So, I think for us, we have tried to grow very slowly and very strategically as opposed to quickly and for a certain number. So, on that side, we've still been able to add really good likeminded partners to join us along the way. And so. We're, we're excited to continue to be able to do that because we're maybe not over our skis like some others, but I would say just in general, I'll say the inflationary pressures are really tough on the margins these days. I mean, certainly wage inflation is first and foremost, but you know, everything else that goes along with it, supplies and those sorts of things. And so, we think about, you know, what have been those. Those pressures and how might we be able to respond to them? And we know the point of care delivery is first and foremost. So, despite wage pressures and some of those sorts of things, we have to have really great clinicians that love what they do, and we've got to have. The support staff that are able to, to give, give a great experience and support that clinical delivery of care. What we know is most people still prefer and like that in clinic experience. So, we have challenged ourselves to think about the nonclinical cost management, right? The admin side and some of the other sides where we can maybe help reduce some of that overhead. Cost inflation here without jeopardizing the patient care and the patient experience. So, we've seen it all the way around. And so, we're just trying to think about how we might respond in some sort of innovative way again with technology with, you know, alternative labor forces, things like that.
Richard: Yeah, I think culturally, you know, your organization and mine are very, very similar with regards to the approach. I often call you know, talk about the tortoise and the hare. I'm very happy being the tortoise because eventually, ultimately the tortoise wins. Yep. And I'm still obviously, in the race that I think the tortoises have made great progress in the last 18 months where perhaps some of those pairs have struggled a little bit and are taking a breather. But anyway, moving on to 2024 I'm really excited for it in many ways. I am apprehensive. I'm not going to get me wrong. But you know, with patient demand high and increasing the clinicians that are being trained academically are very good. You know, when I compare myself, my level of academic training compared to theirs, you know, theirs is much stronger. Perhaps their expectations of the profession might not be quite the same, but you know, that's perhaps another topic for a different podcast. Inflation seems to be at least coming under control, perhaps I'll touch wood as I say that. So, 2023 from a visit volume perspective, I think was robust for many of us. So, what do you, what do you think, what are you thinking about, how do you think of 2024 perhaps for private practices and outpatient physical therapy?
Steve: Yeah, I think like you, I continue to be really encouraged about the patient demand and that, the consumer choosing us, more and more so directly. So, I love the fact that direct access continues to grow in the space, and that's likely where we should be and not just waiting for somebody to send us a referral. And even in places that have recently gotten direct access. I see many of our colleagues really embracing that and thinking about themselves as a direct musculoskeletal provider here. So that is certainly a place of optimism for me. And I would say like you, right? We see the inflationary pressures easing a little bit. I would even say in the last couple of months, I've even seen the labor issue ease just a little bit, too. So again, it continues to make me hopeful. I think again, what I really love to see is we do have some really engaged new young professionals. That is what fills the tank, right? We want them to be clinically excellent. We want them to have great things. Patient rapport skills and then demonstrate that value every day because we have to continue to fight the battle for the future of outpatient and private practice. And so, you know, I think we have to understand that the care we give to people is beyond our treatments. And so sometimes I think in the past generations, we were kind of hung up on our technical proficiency. And I think we know that in this consumer driven healthcare world, that the care that we give is inclusive of the experience and the trust factor. And that is unique to our setting. That's what I really feel like, like every private practice on every corner has had that rapport with patients that leads to high trust. And so ultimately what I want is our new young providers that are not on that burnout track. And I think we also see to be engaged right to something. And so, engagement, I always think about our purpose. Why did we become therapists to our people, which is our local team and maybe our broad organization? That just continues to have the passion to bring what we have to offer to folks, I think, is really great. Certainly. We need to continue to tackle the reimbursement, the regulatory issues, the advocacy around all those sort of things. But ultimately, I think it starts and ends with a really great clinical experience for patients and, you know, really demonstrating that we have the value and again, value is in the eyes of the stakeholders. But for patients, it is the trust factor that we get them to a good functional outcome. And that more people want to do this. I think we did this right? While the applicants to PT school have gone down and continue to do so. It's still pretty. It's still pretty strong. Again, I was ironically on a board call for the institution that I used to be involved with. I'm still on the board there. And so, the number has come down historically, maybe too. From 750 to around 625 for a class of 60 or 80. So, you know, there's still plenty of people that want to do that. And I talked to young people that are not yet in PT school, and it still seems to be a relatively sought out profession. So again, we can also look at the U.S. News and World Report that says. PT Is the 10 best job overall 10th best and in health care, it’s number three. So, if you are going to be fighting this battle in health care, we know that what we have to appreciate with patients is really unique and different. So, I'm an eternal optimist around private practice and feel like, you know, our young professionals that come in that we see every year. They have that drive and what we hope to do is not let them go down the path of disengagement by all of these other challenges that we talk about that we can keep people engaged for PT and, continue to see them go along a career that is satisfying, both personally and professionally.
Richard: Yeah, no, I think that's a great point when we talk about employees. I think that it's the first time where there's, I think, five different groups of generations in the workforce. Yeah. And certainly, I feel, I definitely feel one of the older generations now. And I struggle a little bit with trying to understand the younger generation. I assume it's just getting old. I will try my best. Don't get me wrong. But you know how I manage and lead my team has definitely changed. And it's continually changing how I managed 20 years ago would just be a complete failure. Now the expectations I have have had to be adjusted. And I think 2024 I'm going to have to continue to adjust those expectations considerably, to an environment that perhaps has different types of values and also flexibility. And I'm sure you're already doing a lot of things as an organization to address that. So, I'd love to know your thoughts about 2024 and beyond. And what type of work environment do we need to provide to our team members, employees, employees?
Steve: Yeah, I think we really need to find what kind of calls to them. And so, when we think about engagement, there's the Gallup definition or many others that I think, but I love to revert, to not only being physically present, but psychologically committed to the purpose. And certainly, our purpose first is being a PT. And then it is, I think about the people first mentality. We grew up in the generation of strong work ethic and always put the patient first, the customers, right. All of those slogans, but I think we've come to find that. Each individual has to be in a good place themselves, and they have to be not only supported by their team, but willing to support the rest of their team. So, I think we've really come to believe that we have to be in a good place ourselves as providers. To be able to put patients first because if we're not in a good place and we read about the mental health impact and the burnout, the stress, the job satisfaction. So, I think we revert back to, you know, how are we doing? We still certainly need to keep clinics open necessary hours, necessary days. So, it's not something that we say, hey, go work from home and do this. But I think there is an openness to making sure that we're meeting people where they're at, understanding what they're looking for, as long as it's reasonable about what the business needs, then we've been open to that. But I think we really have thought about this people's 1st mentality before we can get to putting the patients 1st. And so, again, we want people to have not just a work ethic, I think that's put your head down and do it. We would love for them to have some fun and have some joy and be connected to both their patients and their teams. Because you know, that's the long run to your point of the tortoise and hare. Another place is we want them to have good. Professional growth, both clinically and personally, and we just try to put people on a path that way. I don't think there's any one characteristic, but the new generation is different, and we've got to just understand that their values are something we have to become familiar with and adapt to as well.
Richard: Yes. You know, with the different generations, it's not as if there's a good or bad generation, it's just different, isn't it? In fact, in some ways, I would probably say the younger generation is probably much more healthy in their approach to life than perhaps I've had with regards to the kind of, put your head down, work for a company for 30 years. You get your service in, you're loyal to that business and, and you do whatever it takes for that business. And, and oftentimes, unfortunately, compromising one's own kind of other components of life. So yeah, the times against us a little bit. Do you have any other thoughts with regards to 2024, as you look into that crystal ball as it pertains to what to expect, anticipate or challenges or even opportunities?
Steve: Yeah, I think again, the challenges will be ones that are familiar to us. So, I would hope we're kind of adapting with an offense that is responding appropriately to those sorts of things. Again, you know, how we run our businesses are relatively the same, right? We want patients that we want providers. So, it always starts with that. And then we have to be strategic about how we can innovate going forward, whether it is, trying to streamline our administrative costs. I think that's probably a unique opportunity here. But I think that requires a mentality of not just doing it how we did 5 years ago and 10 years ago, things like that, both with you know, labor solutions, technology solutions. We need a therapist. We need patients. So, we have to build our business around that. And so, I would say that. You know, again, we hope with repetition, some of these, some of these fights that we have are these challenges be it reimbursement and regulation and admin burden that we can't, we can't take our foot off the gas. We have to continue to get more people with more voices and really, I'm a full believer that we got to use our patient base as our legion of raving fans to talk, to talk, tell the story, be willing to, you know, send a note to their legislator and make a call. Use some level of influence and then hopefully again, some at some point we know the insurance plans kind of have their offense. So, employers, I think, are starting to think about where we fit into the model and hopefully, they'll have a position of strength too, because those are the folks that are funding an awful lot of these benefit plans. And we've, we've kind of seen some of the work in the PT first model. The conservative care model. So hopefully again you know, the employers will also start to adopt some of this, but I would say that some of the industry challenges are not unique and different save some of them. Strong labor pressures, the other things we've been managing. And so, I hope that you know, some of the macroeconomic things will continue in the direction that we're seeing now. That will take a little bit of pressure off margins. And then we just have to continue to say that our earlier point is, if we can reduce enough of that admin burden, maybe to see. One or two or three more patients a day is what we need to do. We don't want to get to where we have to see, to your point, when we were young clinicians, north of 20 or 25 a day, that just isn't going to go. But, you know, if it can be a couple of more, we can keep the economics supported, then it's just a matter of what's that day-to-day life for our therapist. And are we supporting them both personally and professionally?
Richard: Before we finish what's been, I think, a great conversation in regard to summing up 2023 and looking at 2024 and beyond I always ask for perhaps whether there's any words of wisdom for our listeners?
Steve: Yeah, I would just say not to be afraid to enact some change. We know change is inevitable. We don't all love that. But I think if we're hesitant to change or innovation or technology or some alternative processes here that we've touched on briefly today. I, I just think we'll be on the outside looking in. So again, we're all facing the same things as an industry. While we want some of these wins that we need badly, we can't like to sit back and wait for that to happen. So not to be afraid to take some advice from friends or colleagues or other people that have done things in a different way. And I would just say our public is really seeing this innovation and change all before us, how business is being delivered, whether it's e-commerce or you know, we attach that to digital or self-service models from the admin side, all those sorts of things our public is ready for. And so partly we can maybe become a little more innovative from how we delivered care and. Provided a business experience from the last 10 or 15 years, so not to be afraid of trying some of those things that's right for you and your practice and where the opportunities may lie in your communities.
Richard: Again, thank you so much for your time today, Steve. It's been great chatting with you, and I look forward to listening to the podcast, not only in the next week or two, but actually in a year's time to see what's actually transpired. So, so thank you. I really appreciate your time.
Steve: Thank you, Richard.