Challenges and Opportunities in Physical Therapy Regulation

Alan Fredendall // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of healthcare & rehab as an industry, who the big players are, what (if anything) is being done to change things, and how individual therapists can begin to affect meaningful change

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

ALAN FREDENDALLGood morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan, the pleasure of being our Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete and Practice Management Divisions. It is Leadership Thursday. We talk all things practice, ownership, business management. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday comes directly from ICE's CEO, Jeff Moore. sent this to me last week said hey I was just goofing off in the gym trying to get some lifting and cardio in together and so he sent me a workout of 100 bench press with the weights on the barbell 135 for guys 95 for ladies and a hundred calories on a fan bike for guys 80 for ladies with the caveat that you can break up that work however you like you can Do 100 bench press straight through, 100 calories on the bike straight through. You can break it up into 10 rounds of 10 and 10, 20 rounds of 5, 5, 5. Whatever rep scheme suits your fancy, you are allowed to do that as long as you get all of those bench press and all of those calories done. that bench press weight should be light to moderate for you enough that you could potentially do five to ten reps unbroken. If it's so heavy that you could only do maybe singles or doubles or triples it's going to take you a long time to work through a hundred so keep that in mind. Other than that just pace yourself on the bike. There is no use racing that bike to finish a couple seconds maybe faster than normal only to lay on that bench for 30 seconds before you feel like getting some reps in. So just treat it a moderate approach on that bike and hammer out that bench press as able. So that is Gut Check Thursday. Today we're talking about changing the status quo. What does that mean? We're talking about the status quo as it is across healthcare in general, but of course specifically to rehab today on PT on ICE. So we're gonna talk about what is business as usual in rehab, who are the major players, We're going to talk about what is currently being done to address some of the issues across the rehab professions and again in particular physical therapy. And then are there more effective ways to try to change things. WHAT IS BUSINESS AS USUAL IN REHAB? So let's get started first by talking about what is business as usual. And in the rehab industry, the healthcare industry in general, we have what is really going on across pretty much every industry in the country of a slow merger acquisition consolidation of small to moderate companies being bought out by larger companies and slowly paring down the amount of organizations who really offer the same or similar service. A good representation of this is the airline industry. We only have four major airlines left. Southwest, Delta, American, and United. 20 or 30 years ago, there were over a dozen. And in the wake of some of the IT issues we had last week, we may even see that Delta and American could be going away soon if they don't fix their IT infrastructure and get their feet back on board. And so we see that there are just a handful of major players in the industry. And we would label those too big to fail kind of organizations. We have the same phenomenon going on in physical therapy and again in healthcare in general. When we look at healthcare, when we look in particular at rehab, we really have four major players. We have health insurance companies that control the care that patients are able to receive. and the amount of time providers have to spend paperwork wise on providing that care and also the amount of money that providers get. We know that almost every American has health insurance and so that health insurance for the foreseeable future is going to be part of the equation and therefore these health insurance companies are a big player in this industry. We have just a handful of health insurance companies, about 10, that generate $1.3 trillion collectively and employ over half a million people, with an average profit increase every year of about 9% year over year. And these 10 companies insure about three-fourths of Americans. So again, a very consolidated, condensed industry. where if any of those companies were to go out of business or something, it would have a lot of ramifications for the economy, for patients, and for providers. And so health insurance companies stand as one of those too big to fail type of organizations in this equation. Right after health insurance companies are health care companies. Large, national, across state lines, corporate, health care clinics, whether they are primary care clinics, dental clinics, urgent cares, physical therapy clinics, whatever, we see the same issue across all health care professions is that over time we are slowly paring down that the vast majority of clinics are owned by a large corporation and that usually as we get near the top of these organizations, Nobody involved in the leadership or management of the company is actually a healthcare provider. And so these are large, for-profit clinics that provide some sort of healthcare treatment. In the rehab industry and physical therapy in specific, just eight companies are closing in on owning 75% of all outpatient physical therapy clinics. And so that's very similar to health insurance, right? A small amount of companies own the vast majority the organizations and clinics within the industry. We have universities as our third player in the equation. They are responsible for educating entry-level students and getting them prepared to become new clinicians. They certainly have a stake in the equation here. And then finally we have the government itself. That can be kind of vague when we say the United States government. We're kind of really referring to enforcement organizations, Medicare, IRS, who are trying their darndest to try to regulate the other three organizations, big players in the industry. And what we find when we look at the intersection of all these giant, large, too-big-to-fail organizations is that we find that Over time, they have become intertwined. They have developed a symbiotic relationship with each other such that it would be really hard to affect significant change on one piece of the puzzle without it affecting everything else downstream. We see that universities have grown their cohort sizes so much that they are now graduating hundreds. Hybrid programs with multiple cohorts starting per year are getting close to graduating thousands of physical therapists per year. And all of those students need clinical placements. Those large corporate health care clinics are happy to take those students and put them to work for some free labor. I think we've probably all experienced that. at one point or another in our student career. And when those universities grow these cohort sizes, they begin to need those large clinics to have places to send their students to. And those clinics rely on those students, again, as part of their labor force alongside their staff therapists as well. We see that health insurance companies need, at some level, some providers to take their insurance so that they can offer to their customers, our patients, that there are some providers who take your insurance. If we get to a level where no one is taking insurance, health insurance companies are gonna be in a lot of trouble, and so we see that they are trying to hang on and kind of fight back against a shift across healthcare towards cash-based physical therapy and trying to go around the insurance system. And then finally we see that the United States government hasn't necessarily quit trying to enforce curb all the fraud waste and abuse in Rehab in health care in general what we see is they've kind of changed their policy over the years instead of throwing people in jail or busting up companies or that sort of thing that they have shifted their strategy to just collect fines right if they can't and stop it, then they will collect a piece of the revenue that all these different organizations are making. And so you see that fines are becoming much more popular than actual legal action when the government tries to get involved in significant issues with fraud, waste, and abuse in healthcare. So that's business as usual currently. Universities pumping out students, big corporate clinics taking students, offering students a job, health insurance companies playing both sides against the middle and then the government just trying to come in and take a little bit off the top at the end of the day. And really what we see happening is at the end of the day, there's really no impetus to change business as usual, the status quo among those four groups. It is working well enough that there is no significant push to really change things. WHAT IS BEING DONE TO CHANGE THINGS? What is being done to change things? You may have noticed what we did not mention in one of those big players was an organization like the American Physical Therapy Association. Not much is being done here because not much can be done. If we take a second, and please don't hear that this episode is just an episode designed to dump on the American Physical Therapy Association, but structurally it is not designed to hang on and try to enforce or weigh in or make any sort of decisions or affect really a lot of long-term change on any of the issues we see among the big players in our industry. That when we look at what is the APTA, really it is a non-profit member organization. It's not a charity. It's not a church. It's a member organization, it's a non-profit, it doesn't pay taxes, and so at the national level it really can't affect change. Nothing about our profession is regulated on the national level, it is all regulated on the state level. Your scope of practice, whether you can manipulate the spine, dry needle, whether who can prescribe exercise, who can do cupping, who can do blood flow restriction, all those different scope of practice issues are all handled by individual state legislations. And because of that, the APTA cannot really weigh in. They can also not weigh in because they can't legally weigh in. When we look at how the APTA is structured, it's structured as a non-profit corporation. It is forbidden by law, as is every non-profit company, every church, every anything, from engaging in political activities. So what the APTA has is a secondary organization called the PT PAC, the Political Action Committee. That is an entirely different organization. It's an entirely different pool of money. And that is the group that can try to lobby for things like mitigating Medicare reimbursement cuts. But that in general, on the national level, by design, it can't be effective. And just being an APTA member without donating any extra money to the PT PAC itself doesn't really allow us as individual clinicians to help the APTA effect change either. HOW DO THINGS ACTUALLY GET DONE? So, how do things actually get done then? Things really get done in our profession at the state level. State legislation, changing scope of practice, doing things like expanding direct access, opening up the ability to dry needle. We saw Washington just get access to dry needling a couple months ago. That was a state-led initiative from the clinicians in that state, from the state physical therapy chapter, and from the state legislature in Washington. That is how things actually begin to move around in our profession. And the unfortunate thing is you cannot join, just join your state chapter. You have to join the APTA and then also join your state chapter at the same time. So you can't be a part of just your state without being a part of the national organization, which I personally believe is a little bit unfortunate because I'd rather see my time and money go towards the organization that's going to affect the most change, which is going to be my state chapter. A really good example right now, we're close to completely removing direct access restrictions here in Michigan, and that is led on the state level. A guy over on the west side of the state, Dustin Karlich, he is pushing that initiative with the Michigan State Physical Therapy Association through the Michigan State Legislature, and we're hoping that that gets heard in the fall meeting of the state legislature. and that we have direct access restrictions completely removed here in Michigan. And again, that is all done at the state level, not at the national level. So what can we do? What can be done? If that is the status quo, if that is what is currently being done, and most of it is being done at the state level, What can we do to try to change the status quo? We hear a lot here at ICE, you know, what is being done about this issue? What is being done about that issue? And the truth is, not a lot, right? We're not expecting to see reimbursement probably go up ever again. We've talked about why that is. The math just doesn't math with that. And so if we can't meaningfully affect the change that we want to see, especially at the level that we want to see it, what can we do as individuals and what can be done to try to change things in our profession? The first is to recognize, like, hey, we're in a Cold War event, kind of, right? These big organizations that don't really want to change things are pitting themselves against each other, and again, they don't really have an impetus to change. We see a lot of proxy fighting going on, arguing back and forth about who and who cannot dry needle or use cupping or blood flow restriction or whatever. We kind of have these proxy fights across the country. We go back and forth constantly. And the truth is, we need to recognize, hey, how did we actually win the real Cold War? We've significantly changed our strategy, right? How did we do that? We stopped expecting that doing the same thing over and over again would create meaningful change, right? We stopped going into small countries and propping up a government to fight against the Soviet Union. We recognized after 50 years of that, that that wouldn't work. What we did instead was we shifted to focus on our economy, we shifted to focus on being self-sufficient with natural resources, and we went an economy-driven strategy instead of a military-driven strategy, and that's what actually ended the Cold War. We see a very similar recommendation here inside the PT profession. What is the strategy? Literally anything except what we're trying to do, which has not worked in decades. This is one of my favorite books of all time. This is a hefty book. None of you are probably going to read this. That's okay. This is Army FM 7-8, Field Manual 7-8. It is infantry tactics. What I love about this book is probably a thousand pages of how to fight a war. What I love is that almost every section starts with, if what you're currently doing is not working, stop trying to expect a lot of change by doing the same exact thing over and over again. Change your strategy, right? Do the unexpected. There is a whole page in here on how to react to an ambush and the first sentence is, if ambushed, attack back immediately. Why? It is the unexpected thing to do. We have to do the same thing in physical therapy. Do the unexpected strategy because the expected strategy, the thing we've been trying, for the past 50 years or so has not really changed anything and we should not expect that doing the same thing over and over again will affect any sort of meaningful change. If we just stick our head in the sand and say, certainly someone is going to fix all of these issues soon, we should not expect that those issues will be fixed anytime soon. So, what are our recommendations? Support your local state PT association. You can't join it directly, but you can support your state PT PAC, your political action committee, which means that you can give money to your state physical therapy association that they can use to pass meaningful legislation in your state. So if you're in a state and you want access to dry needling, you want access to spinal manipulation, cupping, blood flow restriction, you want better direct access, you want whatever, it's going to change most likely at the state level and so support your state level association. As an industry, as a profession, we need to recognize that slowly over time, we're moving towards a state where it is not going to be possible to accept every single insurance and run a sustainable and profitable practice that lets us pay our therapists what they need to make to make a decent living while working at a reasonable volume, right? We have moved over the years from 40 patients a week to 60 patients a week to 80 to the average now is climbing towards a hundred patients a week that is Unsustainable and the again the idea that we can just do the same thing over and over again and expect change is not going to happen we're not going to to really make any meaningful change by trying to see a hundred patients a week or 120 patients a week and to try to generate more money to be able to pay more people. There are limits to how much you can get, how much you can work, and we need to recognize that over time, if things don't change with insurance, we need to let that ship sail. That is a tough transition, that is a hard transition, but it is a transition that is going to have to happen to some degree at some point in time for almost every physical therapy clinic in the country. unless things meaningfully change. How can those things change? There are systems in place for us to report our outcomes and increase our reimbursement from insurance. Almost nobody does that because it takes time, but it is possible. We're going to see our reimbursement here at our clinic here in Michigan go up 20% in 2025 because we are reporting our outcomes and And we are getting rewarded with more reimbursement. So there are systems in place, but if you don't want to use those systems or do those tasks, you need to recognize that you need to let that insurance ship sail. And it means that you're not going to be on it. And then over time, we'll need to probably pare down our insurances and potentially be cash only across the majority of the profession. And then as individuals, what can we do? Yes, we can support our state physical therapy association and state PT pack, but we can also stick up for ourselves. Every time you go to work for somebody that overworks you and underpays you, you confirm to the leadership of that organization that there is another sucker out there who is willing to accept that, right? And we just perpetuate the cycle that we have been trapped in for many decades. And again, what is the best strategy? Anything different than what we're already doing. So when you are given that quote unquote opportunity from that organization, and it looks terrible, don't take it. There are 34,000 physical therapy clinics across the country. Find a different one. There is a clinic for you that is going to pay you well and respect your time and autonomy. I guarantee it. It just might not be three minutes from your house, right? We sometimes need to choose a little bit of discomfort to make a meaningful bump in our own individual practice and our own individual work inside of the bigger profession. SUMMARY So changing the status quo, recognizing we're kind of stuck in a cold war with several organizations that are too big to fail, that don't really have an impetus to change what they're doing because it's working well enough for all of them. What is being done currently? Not a lot on the national level because it can't. We have to stop expecting that black helicopters with agents in suits from the American Physical Therapy Association are going to drop out of helicopters and just fix things. There are only 160 people that work at the APTA. Almost all of them are administrative roles. There are very few people there that are doing a lot of of groundwork because the groundwork of our profession happens at the state level. So what can we do to support that? Support your state physical therapy association. If you're like me and you don't want to join the American Physical Therapy Association just to support your state association, you can still support your state's physical therapy political action committee PAC PAC by donating money. If you go to that website I think you'll be surprised by how few people donate and in reality how much gets done at the state level with a relatively small amount of manpower and money and that if we all just gave a hundred bucks to those organizations I think we'd be really surprised at how much more change we see affected if only in our individual states, but how effective and how large that change could be across our profession. So, when in doubt, if your courage strategy is not working, literally do anything else, right? Write from the Army Field Manual. If you are being ambushed, attack back because that is the strategy that is least expected. Do something different. Go around insurance companies, support your state political action committee, and stop working for employers who don't respect your autonomy and who don't respect your livelihood, who are trying to overwork you and underpay you. That's all we have for today's episode. I hope you found this helpful. I'd love to hear any discussion you all have about this. You can leave a comment here. I'll be back tomorrow. We're gonna talk about Fitness Athlete Friday, how to develop really brutal strength in a way that translates to improvements in your Olympic weightlifting. So we'll see you again tomorrow morning. Have a great Thursday. Have fun with Gut Check Thursday. Bye, everybody.

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