Sunday, January 19, 2014

Future Thoughts for Private Practice Physical Therapy

Private Practice Physical Therapy (PPPT) 

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way." - Tale of Two Cities, Charles Dickens.

I feel that the quote above truly describes the state of affairs in PPPT. Never in the history of the industry has so much potential been met by so many barriers. With the chaos in the healthcare industry at large, the instability of the economy and marketplace, as well as the terribly amorphous state of physical therapy practice in its vast diversity - it is getting harder for suppliers to convince consumers in the value of a private practice (and many times cash based/out-of-network healthcare service).

Bleak. Huh?

Well, I was asked a little while back to describe my vision of a Utopian, outpatient PPPT clinic. As you know, while being an overall optimist, I'm a realist, a tactician, and a businessman. Despite the picture being painted in such depressing colors, I believe there are still many venues for which physical therapists can strengthen their position in market. Additionally, there are new possibilities which will not only redefine physical therapy, it will redefine certain facets of healthcare (by which, REMIND me to write a post on the futures for future thoughts on inpatient PT).

So, here's my vision:

I envision the future proprietor of PPPT to serve as an owner of businesses, a provider  in outpatient clinics, a health/wellness consultant, a concierge home health practitioner, as a health fair/conference/talk-show/media speaker, a retailer, and as a community leader.

As an owner: I see PPPT as a bankroll to own properties of strip malls, commercial office buildings, and the like. I see the openings for owning fitness gyms and even renting out to or owning (if able in respective states) massage therapy, acupuncture, chiropractic, nutrition retail, beauty salons, and any other associated wellness venues - in this vein, some people say "If you can't beat them, join them" - I say, "Just own them!"

I also see massive potential for PPPT in retail. I've already published some content on the matter:

The bottom line here is that physical therapists NEED to learn both the service business and the products-sales-retail business; there are many lessons to be learned from optometry, dentistry, chiropractic, and general retail. If there is any DME, orthosis, or any such health product you recommend or already place orders for, you should be retailing it!

HOWEVER, perhaps where the greatest opportunity in the future of PPPT is located is in primary care. While the future of healthcare is still quite uncertain, the future of human health remains largely predictable. People need a reliable expert for physical health. A primary physical therapist or a family physical therapist is desperately needed much in the same way a family physician, a family dentist, or a family optometrist exists in the market today. The pediatric PT for the growing family, the geriatric PT for the aging population, or your primary care generalist can all serve a very large market share for those who are frustrated with canned-fix-all "800mg of Ibuprofen mixed with muscle relaxers" - and/or - the ever popular "Well, that pain is just arthritis - you'll learn to live with it."

This type of primary care PT provider needs to expand past intervention and expand into yearly or biannual check-ups, wellness, pampering, prevention, and public education. This should also include hours of the day dedicated to concierge home health visits - a fairly profitable market, indeed! All this leads to an expanded exposure to the market at large; imagine when a family, very happy with your services, invites you to the kid's classrooms to talk about health for "show & tell".

Almost every kindergartener knows to "brush your teeth and floss daily." Imagine an entire generation who know from age five, if you are having pain, struggling with play (movement), fitness, or exercise - or - if you happen to have any muscle or joint problems; well then, it's time to see your family physical therapist! This type of appreciation elevates the PPPT to a point beyond a savvy business operator and expert health provider; this level of appreciation makes the future PPPT a community leader. Ever think of going into politics? Hint: expanding awareness, direct access, elevating scope of licensure.

Dreams to Reality:
Again, I'm a realistic and tactician - there needs to be a viable path to connect the dots to make such dreams reality. Here are some ideas:

First: *Quick soap box moment* When you Google "physical therapy," what do you see?
Apparently, the public thinks PT is passive range of motion, gait training, and perhaps ball exercises. Is this REALLY what we want? I've incessantly been on the soap box of brand image vs. brand identity in that brand failure occurs because a firm focuses on their own perception instead of the perception of their customers. Specifically, failure here commonly occurs because firms are silly enough to think that if they do the "right thing" in their own eyes, the public will be on their side.

For our industry, the naivete that the public will spend their dollars with sensibility/science/logic is an ongoing fallacy that only causes infighting within the profession - NOT helpful. Not convinced? Take a look at all the businesses in any industry that are not "evidenced based" but are obviously producing both experiential & financial outcomes satisfactory to the consumer. And, take a look at the bantering if not outright destructive arguments that are occurring in social media due, primarily, to personal (not professional) pride. It helps no one when methods, research, and/or experts are championed or demonized as an everything works or nothing works. ESPECIALLY in the current climate of evidenced based practice/medicine - we are only hurting our cause of solidifying a strong brand when research is purported as "nothing we do actually works" WITHOUT offering solutions to replace once viable interventions. All that such interactions are doing is narrowing the already limited scope of practice available to physical therapists - and - what is worse for PPPT, this is only decreasing the earning potential for reimbursement that insurance companies are willing to offer.

And so, I can't stress enough: consumers want to see brand UNITY (several posts on the matter are available below):

Inconsistency/infighting tells consumers to go somewhere else. Best example? Franchises. When some are good & some are bad, many consumers just go to the competitor. The lack of unity in the physical therapy brand is a failing causation; and, when a brand is failing, you rebrand. Period. To do otherwise with a good service or sound product is business suicide.

Enough of that. *Off soapbox*

Tactic: Marketing using an Island Hopping/Anchor Method
The best way to execute such a tactic is to find a (generally universal) signature moment for the common entirety of physical therapy (or whichever brand you are trying to pursue). This signature moment will become the definitive image for which the consumer will have in their minds as & for your brand. This image must also be adopted as your brand identity (even if this isn't what your ultimate goal is to be).

Now stay with me! This bit is a little long, but it all comes together at the end of this section.

Once you anchor this position, you have a strong base of fire for which you can launch an expansion. A possible example could be this: "Physical therapists specialize in recovery from injury." Translated: "If you get hurt, go see a physical therapist." This image implies that physical therapists are the experts which one can rely upon if one is experiencing pain or has gotten hurt in any way shape or form. While this doesn't even begin to cover the scope of what PT's do, this is a very important start.

From this starting point, we can build goodwill with the consumers we serve - starting grounds should be in the states where licensure is more limited. Conceptually, the conversation could unfold like this:

"Glad I was able to help you recover, Mr. Smith. You know what's interesting, I would've been able use more tricks of the trade if physical therapists weren't so limited in this state. Did you know that even though my doctorate degree teaches me how to (pick the most limited element in said state) diagnose, interpret imaging, read lab values, prescribe basic medications, perform joint manipulation, utilize dry needling, directly access my care, etc. - and, it is allowed in most states, you don't have access to such rights under my care?" This is point of service advocacy.

Whatever the battleground needs to be, using the brand experience of injury recovery (for this example), is the best way of expanding the brand to the next step. Example: it isn't too far of a stretch to say that: "If my PT can fix my injury, perhaps I can see my PT every 6 months to prevent future injuries (just like I do with my dentist for cavities)." Voilà! You have now anchored the "injury recovery" brand and now you are island hopping to the "injury prevention/best health primary care" service brand. Anchor down this brand, and the next target is yours for the picking. And yet, the most formidable barrier to brand expansion isn't the marketing aspect. It is the legal aspect. Ultimately, what we are licensed to do (or, not do) limits what we can effectually brand.

Speaking of brand, I know you're thinking: Wait a minute! Didn't the APTA stake claim to the "movement" brand; unfortunately, when you ask the general public about movement, they think about something more like a dance coach... movement simply isn't something the general consumer sees as a matter of healthcare - just my humble opinion. And, when rebranding doesn't occur en masse, it typically occurs in segments. We see this in fitness/personal training all the time with fitness fads. Moreover, we've seen this occur in our own profession with more accentuation in recent times. When one ditches a failed brand concept and begins branding the self, we observe people going to brands such as FMS/SFMA, MDT, NKT, PRI, PNF, NDT, Osteopractor, Kettlebell, TRX, CrossFit, Biopsychosocial, etc. But, why?! Isn't the physical therapist label enough?

Let's face it - private practice is a BUSINESS. In the end, there are bills to pay. There really isn't much time or space for idealism - for what should be or could be... the reality is that PPPT is the ultimate litmus test of what physical therapy is actually worth in the marketplace. When the blanket brand of physical therapy yields the images above... the brand is (in more than one dimension) failed for the private practice segment. Sure, there may be plenty of momentum in work-comp, large health systems, and/or inpatient care - however, this means very little to the private practitioner who has financially attached their homes to their business.

The only way the business can make a better profit is by churning more revenue. And, the only way to bring in more revenue is to expand the legal scope of practice. The marketing arm in this equation is to make well-known the SERVICES available; not the body of knowledge which surrounds the expert - for the consumer doesn't care about what you know. They care what you can do about it and how well you do it. Given, the "know" is more of an authority check point for what you do, certainly important - consider the know vs. what with an orthopedic surgeon. When they are recommended, they may make mention to how well credentialed the individual is, but ultimately, the prospective patient cares about their reputation for good surgical outcomes. How good is the surgeon at surgery? Are they allowed the perform the techniques they say they can do? The consumer could really care less about the rest of the information.

The same goes for physical therapy. FMS/SFMA brands for a systematized analysis of movement patterns to tease out and ultimately correct painful dysfunction. MDT brands for a uniform (again, UNITY!) method to address directional pain - primarily circulating around the spine. The newly trademarked (very smart business move, by the way) osteopractic approach focuses care on spinal manipulation and dry needling. These are services - and - the service is the brand. This service is the signature moment. And, it is from this signature moment that an entire industry can launch rebranding, brand expansion, legislative moves, and increase public goodwill.

The very definition of a brand includes consistency, a product/service which is uniform and reliable. In my interview with Cinema, I define a brand as:
"I define a brand as a symbolic, conceptual identity by which consumers imagine a firm’s services and products with accepted (or rejected) uniform consistency."

So my challenge to all of you: to private practitioners, business owners, managers, directors, to APTA leaders, and especially to #DPTStudent's - universally commit to getting over the uniqueness of your practice, your specialty, and/or your approach. Sure - our knowledge content may be movement & health. But what is our unified signature service moment? We need to define this service image - this moment when our consumers go "Ah ha! THIS is why I come to you (instead of someone else)." On this: what the above private brands are doing correctly is focusing on that signature moment - that's why they are in business! Plain and simple. As mentioned in one of my oldie posts, what our industry needs most is a Mickey Mouse Moment (see here & here) in order to launch a more effective marketing campaign in unison, as ONE profession.

So... what's our signature service moment going to be? Once we define this, expanding practice is just a matter of time. But, until then, our profession is building a brand structure on shifting ground. You want direct access? You want diagnosis rights? You want the ability to order labs, imaging, and prescribe medications? Do you want the military model? Would you like physician status and more authority to make a difference?


Tactic: Community Leadership - Marketing for Future Generations
Here, I'd like to return to the concept of having every five year old in kindergarten know who to go to if they are ever hurt and/or in pain. Linking this to the signature service moment above, it would be best to partner with school systems and have physical therapist participate with physical education programs in K through 12 schools. Let your imagination stretch out once more to an entire generation who knows to get physical therapy FIRST when injured, physically impaired, in pain, or in poor health. THAT can certainly be our future.

This requires that people put their money where their mouth is; it requires PPPT owners to VOLUNTEER their time, energy, and resources at K-12 schools, health fairs, and community events. It is very likely that owners may have to (as some have, and, have won) stick their neck out in the legal world as well. While I understand many take the position that volunteer means free and free equates with less worth - I'm calling this concept out as short sighted marketing sense. This "free" is actually adding value to the marketplace community. It is raising goodwill which is generally considered a priceless heirloom in the world of business.

Since schools can't afford to have a PPPT contracted during Physical Education (P.E.), it makes most sense that absorbing the cost as a PPPT investment to raise goodwill amongst the students and parents/guardians is the best way to also involve the TEACHERS (powerhouse group, right there!). Just as years ago, so many kindergarten teachers had a "brush your teeth" time in the classroom (talk about best self-perpetuating marketing event, ever! - The return of investment: Best Paying Healthcare Job out there!), physical therapists have the same opportunity to infuse the service moment making it a part of a growing K-12 culture.

Pushing this envelope a bit further, I suggest that one of the best ways to get truly visible is to penetrate politics - the becoming of local leaders. We have physicians, lawyers, dentists, and such who pursue community leadership from a political/legislative arm - why not physical therapists? How else do you think we're going to demonstrate the value of our service (and knowledge base) at the media outlet scale?

Tactic: Encourage (if not favor) PPPT Affiliations in DPT Programs
We all know this to be true: students are generally considered free labor. Of course, effectively training, mentoring, instructing, and supervising physical therapy students can also be a labor intensive cost, if not associated risk.  The truth of the matter is that students add value by being generally free when it comes to labor itself. It allows for clinics to redouble their efforts in areas where they wouldn't without the extra body being present. Also, the value of students bringing the cutting edge ideas (not to mention, bright eyed passion) is something that is truly invaluable.

Having a student (or preferably, several students as in the physician/nursing model) consistently available to a private practice clinic will ease long term profit margins to the clinic, strengthening the clinics ability to survive and strengthen its position in the marketplace. This allows for PPPT owners to utilize some of that capital to fight the legal, political, and marketing battles essential to expanding & protecting market share (by the way, if you're not expanding, then you are shrinking). Additionally, affiliations en masse for this setting will foster a culture of entrepreneurial spirits rather than a quite common passive, "stay out of trouble once I get out of school" culture.

Having a mandatory private practice rotation will help the DPT student to learn about the business first hand, and, better prepare them for their own ventures in the future. It will act as a reality check paralleling the didactic experience which will grow a new generation of physical therapists - clinically sharp AND business savvy.

Some Closing Thoughts:
Physical therapy practice for the private segment needs to change. It also needs cooperative assistance from the rest of the industry at large. It does NOT help when "physical therapy" is viewed as walking in the inpatient hallways or  batting balloons in the air - do you really need to be a doctor for that? It is not constructive when sections of healthy skepticism turn into destructive criticism which attacks the already limited tools for which PT's can deliver their interventive measures.

PPPT has great opportunities in primary care, concierge home health (when not in clinic), community leadership, volunteering in the school systems for P.E., and even penetrating the world of politics. Even more so, PPPT has the same right & ability to turn into not just the owner of their own business - PPPT can and should look into becoming the owner of other businesses as well.

Our biggest barriers are legal and internal. While I have strategies to deal with legal aspects via strong marketing tactics - sadly - to date, I have no solution for a culture of unification. There just seems to be too much angst amongst our peers. Unity requires more than the presence of just strong leaders, it requires for a time and place where an entire industry's culture is ready to focus on what makes for a unified front rather than a divergent image.

Personally, I'm more than ready to step into a unified image and sacrifice my individual clinical identity for the greater good. This requires for all of us to collaborate with each other, not internally compete (See Nash Equilibrium concept). We have enough external competition pressuring our borders as it is; we must band together and defend those borders. Losing this battle is something we cannot afford; it will destroy our profession. Our selfishness, pride, and apathy are the enemy's greatest allies.

So I leave you with this:

"A single twig breaks, but the bundle of twigs is strong." - Tecumseh

Until Next Time, Yours Most Earnestly & Respectfully,
-Ben Fung


  1. Epic post/rant Ben! Well said, especially about the bantering with no solutions. No wonder you've been quiet for a while!

  2. Skepticism is necessary when the profession is poised on branding speculative interventions that are not supported by the research. We owe the public more than just the promise of pain relief. Which is not guaranteed based on any of the science. Chiros and other CAM practitioners is high on promises but weak on results. We don't need to denigrate ourselves to such a juvenile and science/morally weak position. This will bring down our profession faster than any marketing scheme will. This arm of private practice PT is completely out of control. Time to rethink our brand and ditch the speculative pain promises and get down to doing real hard work with patients. Don't diss acute care PT either.

    1. Eric: Thank you for sharing your thoughts. I'm not sure where "diss acute care PT" is coming from. In case you didn't know, I served in acute PT for several years before taking directorship. I was involved in many program developments at hospital system levels which received peer review accolades and awards. I also piloted ED PT and have been very active in the #AcutePT discussion. I have all the respect for what I formally specialized in and what this segment of practice represents.

      I just saw you reached out to me on Twitter & will respond further there. Thanks again!

      Best Regards,

    2. "is viewed as walking in the inpatient hallways or batting balloons in the air - do you really need to be a doctor for that?" this is what I was referring to. Many in OP world I think look down on IP PT. Esp those in the PPPT, I am not saying you are one of them. I don't know your background and was only reacting to what was written. If it was not your intention then I retract my imperative statement.

    3. ^ I can see where I could've been more clear on my stance. Thank you! That is certainly helpful to sharpening my writing.

  3. Replies
    1. It is my absolute privilege and pleasure! Please let me know (as all #DPTstudent's are welcome) if I can help with guidance as you begin your career path.

    2. Didn't realize my Blogger account was so out of date! Fixed it ;)

  4. Charles Dickens has described life in exact words the situations a person faces during his life and PPPT also has a great concern to provide people pain fre life by providing the services of an osteopath as the life has injuries which really need some treatment from expert and PPPT has provided a great post that would provide them some relief that someone is still out there to help them out in getting rid of their pains.

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