APTQI: Advocacy in Physical Therapy

Alliance Physical Therapy Partners: Alliance Physical Therapy Partners in Agile Virtual Physical Therapy proudly present Agile and Me, a physical therapy leadership podcast devised to help emerging and experienced therapy leaders learn more about various topics relevant to outpatient therapy services.

Richard Leaver: Welcome back to Agile and Me, a PT Physical Therapy Leadership Podcast series. And I’m excited again in my monotone British voice to welcome back Nick Patel. Nick was last with me in 2001 on this podcast, so welcome Nick.

Nick Patel: 21, I think. But yeah [laughter].

Richard Leaver: Exciting.

Nick Patel: Yes. Appreciate being back on.

Richard Leaver: Time flies in the career. So today I wanted to kind of regroup and talk a bit about advocacy, APTQI and really what’s going on. But before we do that, Nick, can you perhaps introduce yourself to our listeners?

Nick Patel: Yeah, absolutely. So, you know, I am the executive director of our group, the Alliance for Physical Therapy Quality and Innovation. And so it’s a mouthful, but I, I have been in the fortunate position to be the executive director for about eight years now. I’m a physical therapist myself. Almost all of my career has been in the outpatient or office space setting. One of the things that I really dedicate a good chunk of my career to has been advocating for better policies for, for therapists. Because I, as wonderful as our profession is and as great it is to see how the things that we do are able to impact people in such a meaningful way, the more you treat, or the least the more I treated, the more I realized that, man, this is a – There’s a lot of artificial barriers, man-made barriers that we have put in place over time that just make delivering care really frustrating. And so that frustration for me led me to a slightly different path, which is, you know, finding ways to advocate and influence and, you know, ultimately make changes for the better.

Richard Leaver: You know, first and foremost, thank you for your work. You know, you definitely are a thought leader within outpatient therapy as it pertains to advocacy and really promoting the profession. And without you, we would not be where we are today. And I’m sure that your influence will continue to really pay dividends to the entire profession. So thank you personally.

Nick Patel: No, I appreciate that.

Richard Leaver: So rather than just talking about the concept of advocacy per se, which we did on our last podcast, I think perhaps what might be helpful is to talk a little bit more about the APTQI, because since we spoke in ‘21, it really has morphed into something that is much bigger now and I believe actually much larger, more powerful voice as well. So perhaps if you could just talk a little bit about that first.

Nick Patel: Yeah, it’s certainly been a tremendous journey for the group. We are in some ways bigger than I ever imagined, but in other ways I think that the growth has sort of led me to understand that there’s a whole world out there of organizations and leaders who really want to get their hands dirty in advocacy. And that has actually been great. So where we are with APTQI right now is we initially started as, you know, a provider-centric group where all the members were operators that had multiple hundred clinics in multiple states. And that was great. Over time we started to say, you know, we would get interest from other members like yourself that would say, you know, we want to join and, and we’re, we’re a bit smaller, we’re not in, you know, 28 states and blah, blah, but we like what you’re doing and we want to help and you know, we’re willing to join. And so we created another membership class and that class has been just explosive for growth. More people coming than, than I ever thought possible. I, at first I thought well sure, let’s, let’s open up another one. But I doubt anyone comes. And of course I was proved wrong time and time again. And then we did this sort of third membership class where we were approached by, you know, companies that maybe weren’t providing physical therapy, but all of the products, the services they did, were used by therapists. So however the therapy profession goes, so did their business. They just didn’t happen to be providers. Maybe they ran an EMR company, maybe they sold DME. Maybe you know, they, they had a technological platform for a therapist to use. And sure enough, same thing happened. We opened up the doors to that and we had great interest from, from folks coming in on that way. So where we stand now is, you know, the alliance has over 30 companies. Whether you’re, you know, multi-state, over a thousand clinics, maybe you’re very regional, 20 to 50 clinics, or maybe you have a platform for therapists to use. You’re all under the umbrella of, you know, trying to do good for the profession. And the thing that has never changed, regardless of how many people we’ve brought in or how big we have gotten, is something that I, that I think is really unique, which is we, we are home to people who compete every day of the week on, sometimes on the same street corner of the same state every day. However, when we meet, all of that is checked at the door and egos and pettiness doesn’t really exist when we meet. And it’s all about what can we do for the profession? Because whatever we can do positively for the profession is going to help me, you and everybody else. It’ll be good for all of us. And I think that again, I like to think that that happens on industries, but I just don’t know if it, if it does. I make this joke all the time, but, you know, I don’t know if the CEOs from McDonald’s and Burger King and Taco Bell meet every month to talk about, like, what they can do to make food better. And my feeling is they don’t because their food is awful for you. But, you know, that’s not what happens in therapy. We are, we’re doing it monthly. I mean, you know, and you’re there, and you’ve seen it. But, and all we don’t talk about, well, my company needs this and this guy is bothering me and we’re competing here. It’s none of that. And so we just been able to continue with this culture from the beginning of ego checked out the door and we’re all going to try to help. And I think it’s made the operators of these companies go from competitors to, still competitors, but actually friends and, networking and being able to lean on each other because no one else knows your job better than the person who has a similar job to you at another company. And I think it’s made for a nice camaraderie. And because of that, I think they were able to maybe make movement and get some things done, which is the ultimate goal because we are able to sort of come together in that fashion.

Richard Leaver: Yes, it’s still a very fragmented industry, hasn’t it? You know, healthcare generally, but outpatient therapy, even with the consolidation that’s occurred over the last 10, 15 years, and for me, advocacy, there’s really two points. One is the message. You have to have a good message. But then there has to be power in numbers and strength in voice. And what has amazed me in the last five years particularly is that voice seems to be at least being heard. Because when we last spoke in 21, I think we questioned to a certain extent, certainly looking back at that point, the voice was very weak. But you know what? I’ve-my perception, particularly in the last couple of years as the APTQI has grown and also, to be fair, as APTA has morphed and evolved from an outpatient perspective, I feel that there is now a voice and proper advocacy occurring. Would you agree with that or do you think there’s just. I was ignorant to it in the past?

Nick Patel: No, I think you hit the nail on the head because I mean, whether it was four years ago or 14 years ago, I think therapists had a group. Not really the fault of any one particular individual or one particular organization, but as a group, as a profession, a bit of a passivity to us when it came to advocacy. And that voice was quite diminished because it was maybe just a handful of people who are participating and you really can’t get very far with just a handful of folks. And one of the things that I think is much better about the industry now is that there’s so many more ways for folks to advocate. I think APTA does a tremendous job with, you know, their efforts and I think it’s amazing what they’re able to do with. Since I’ve been a therapist for 25 years, they represent about like 25% of the profession. 20. It’s, it’s always, it vacillates in between the certain range. It’s always been about a quarter since I think I graduated. And they’re able to get so far with that and in my mind and, but unfortunately that number doesn’t change much and I know that they wanted to change and I’d love it to change. But you know, if you have a 20-year track record of that number staying in, in a similar range, how do we get the other 75% involved? Right. And so, you know, if all things are equal, that probably means 75% of Alliance Physical Therapy Partner employees are probably not members. That means 75% of the other companies’ employees are probably not members. But if we can create an avenue for them to advocate, you know, and combine them with the folks who maybe already are doing some things, then that, that’s got to be helpful for us. Because it’s one thing to have a louder voice by having more people, but one of the other things that I’ve learned is there’s sort of like a, a value to being in the public consciousness and the public discourse. And I cannot tell you and I’m hopefully, I’m hoping it’s better now, but as a 20-something, you know, early career person, I can’t tell you how many times I had to explain to somebody when they said what do you do? And I would say I’m a physical therapist. And they’d say, well, what is that? Or is that they would say something like, oh, I know what that is. That’s kind of like a chiropractor, right? Or you’re kind of like a massage therapist. Or they didn’t have like a really solid view. We weren’t in the public conscious. You probably just went to one when you got hurt. But I, you know, knock on wood, I’ve never had cancer, but I know what an oncologist is. You know, I mean like we should just be at a certain level people understand what, what we are and who we, you know, who we are and what we do. And I don’t think it was there for a very long time. And then so naturally when decisions are made and policies are created, who’s going to be thinking, well how’s this going to affect a therapist if they don’t even know what we do, what we’re trying to accomplish here? And if you, and if you answer the question with you know, I’m a movement expert or I try to handle musculoskeletal problems, I don’t think the public understood what that meant even, you know, again, it makes sense to me, it makes sense to you, it makes sense to people who are listening. But the average person out there, the ways we have tried to define ourselves don’t quite make sense in the public realm. And I think that’s something that as you get more voices helps. But we’ve tried to do things where we get, you know, we try to get more articles just placed in papers about what it is that we do because people actually still read papers. We try to get in news stories, you know, and we’re, because people will watch it. We try to create better handouts and better one-pagers and create better messaging around what does it mean to be a movement specialist and, and not using fancy words and not using words that only other PTs understand but know being able to articulate it in a way that the public will understand it. Because I think that is a huge part. When you talk about cutting, you know, I make this reference all the time. Would you talk about cutting cardiac care? People think oh my God, what are we going to do with all the people with heart attacks? And you think about cutting, you know, oncology people say what about the poor people with cancer? When you talk about cutting therapy, no one understands what that really means because they don’t know what it is that we do. If I could go back in time, I would just make us all “Fall-ologists” by title because I, then someone will say, well don’t cut there because people are going to fall everywhere. And that’s a bad thing because then at least we’re tied to something. And I think one of the, you know, it’s a challenge and it’s not nearly of our doing, but we treat patients across such a large spectrum, not only in one setting, but then think of all the settings that we work in. So from the hospital to the school to the outpatient facility to in, in someone’s home, but then for musculoskeletal abuse, for post neurological disorders, for, you know, headaches, for developmental problems, we just do so many different things, but all with the same degree. It’s very hard for someone to think about, well, if we cut therapy, then this is going to be a problem. So we have to get that out there as well. And I think that that’s helpful for the profession to understood, to get that out there in ways that the general public understand. But also if you’re a policy maker in Washington, D.C. you have to know what therapy does and it’s not up to anyone else to define it. If we allow other people to define it, it’ll be not what we want it to be. So that, you know that that should be our job. And I think that’s one of the things that we’ve tried very hard to start turning that conversation. No one can do it in a day, no one can do it overnight. It takes some time. But I think we’re working on it. And I think that that’s something where it’s a little bit different than telling someone, write a letter and you know, and you’ll change the world. But I think it’s giving people other constructive avenues to make the profession better I think is receptive.

Alliance Physical Therapy Partners: At alliance, we believe that partnership means creating something greater than the sum of its parts. Our focus is finding physical therapy practices with a strong culture and thriving community and providing them with additional tools, resources and expertise to take their practice to the next level. To learn more about joining our nationwide community of outpatient physical therapy practices, visit our website: allianceptp.com.

Richard Leaver: Before we look forwards about advocacy generally, I’d love to perhaps touch upon some of the hot topics at the current time that are affecting outpatient therapy and how advocacy is occurring through various entities, mediums. So one of the things that is definitely of significance is the SAFE act and the impact, potential impact that can have on therapy generally. Would you be able to very briefly explain what the SAFE act is, but more importantly perhaps what the reasons are behind how and why it is so important?

Nick Patel: Yeah, absolutely. So the, the SAFE act in a nutshell is a, is a bill in Congress right now that if enacted, would allow for a Medicare beneficiary who has fallen in the last year to receive a no cost so, so free to them a no cost visit with a physical occupational therapist for an annual fall risk assessment. So that’s not a screen. That is not a let’s do a time get up and go. That is a come see me, I’ll spend 45 minutes to an hour with you. I want to test your strength, your balance, do a home assessment, you know, talk about whatever you know, it is that’s bothering you when you, when you walk or when you’re trying to transfer all that stuff. And I can do all that with that person before hopefully before they hurt themselves the next time around. And it’ll encourage them to come in by saying you won’t have to pay for this. And the, the reasoning behind it is, there’s multiple reasons we decided to pursue this. The first one is the, the, the problem of falls is huge in our country. So the medical cost for falls last year was about $50 billion and 75% of that was borne by Medicare and Medicaid. That, and that number is on a very steep curve and exponentially goes higher. By the end of this decade if nothing changes, we will spend $100 million, 100 billion with a B dollars on falls. And again 75% of that will likely be Medicare and Medicaid. So, and so those are tax dollars. Those are money, you know, that’s money that, being taken out of the other treasury to pay those claims. We have to stop, we have to put a dent in that curve. These are people who are one day ambulatory, living by themselves, independent and after a post fall, you know, put aside the hip replacement or whatever that they have to have done afterwards. But now they’re never allowed to live alone again. They’re not allowed to age in place anymore. Their life becomes over. And then if they have to live with a, with a family member, someone’s staying home with mom, then. So now you’ve taken somebody out of the workforce. Now you’ve taken somebody out of, you know, out of their contribution to society. So falls have a huge problem or falls create a huge problem for Medicare spend. They also create a huge problem for society. So I’m addressing, we’re trying to address a problem. 2: it’s trying to highlight the physical therapy can help with this problem. So again there’s that connection in that, in that public awareness of we can help with a very serious danger to our citizens. And then the third is a little more, you know, you have to dive into it a little bit to see it. But there’s a couple things that I, that we really wanted to accomplish with the SAFE Act. So one was if we need to start seeing therapy as something that people can access before you actually get injured, you know, and we’ve talked about PT should be primary care or PT for the MSK space and all that kind of stuff. We need to start somewhere, though. I’d love to say let’s just start it tomorrow and everyone just starts. It doesn’t work that way. But this is, I think is a good way for us to start to start having that conversation and that we’re not always in there after you’ve had surgery. And what better way to do it than by saying, let’s create a benefit for people, not the therapist. This is a benefit for, for people and for senior citizens to have. And I think you’ll get much better buy in from getting seniors on your side because it’s very hard for a senior to say, I really believe that therapy payment should be more. It’s not their payment, it’s our payment. Right. And they may love us and, and really value what we do, but, you know, they don’t want to get caught in. Well, I like my family practice physician as well. I don’t want him to have to cut for you to get like, it’s stuff that they don’t really want to wade into. But for them to say, I get a no-cost fall risk assessment once a year on the par with being able to get a colonoscopy once a year for no cost, or my blood work done once a year for no cost. But falls are just as deadly to me as maybe potentially diabetes or colon cancer. I think those are the things that again, elevate our profession a little bit. It’s good for our patients and it allows us to tap into an army of grassroots on the patient side that typically a lot of our causes and a lot of our advocacy efforts haven’t been able, haven’t been things that we can get patients really riled up about. And so one of the things I really like that we did with SAFE act was we went to patient groups and took them to this bill. And AARP has come out and publicly supported this bill. The Gerontological Society of America, Families USA,, these are all patient centric groups that have publicly said, yes, we support this idea in this bill. And I don’t think that really happens with the bill that says pay therapists more, but I think it does with this. So that’s probably a long-winded answer to why we decided to attack this path. But I think it kind of, it accomplishes a lot of goals for us at the same time.

Richard Leaver: And there are no losers with this SAFE act, is there? Because, you know, obviously patients, hopefully full prevention or full management, and the cost, as you say, is obscene and incidence is really high. And we talk about incidents of heart attack or cancer or multiple other things, but the number of people that fall is massive with obviously multiple implications associated with that. But there is a carefully calculated financial saving for everybody with this. So it’s a no-brainer in my perspective.

Nick Patel: Yes. Yeah, you’re absolutely right. So we actually included a small provision in the bill that said that if this bill is enacted, Congress should get a report from CMS or HHS saying how many people fell who got the physical therapy assessment and how many people fell who didn’t get one. And then if the group that got the assessment falls less and has less incurring of expenses because of less ER visits and, you know, surgeries and things like that, and potentially removing a need for opioids for them as well, what Congress can do with that is say, oh, wait a minute, for the first time, they’ll look at something and say, here’s a therapy intervention that never existed before. And when we put it in place, we saved money. And because we’re willing to actually write that into the bill, like, go ahead and measure it. We’re confident in what it will show. Go ahead and measure it. I think that lends people to think that, well, what can we go, what can go wrong here? Because let’s go for it, let’s try it. And that’s, I think, why, whether you’re super fiscally conservative or you’re, you know, you’re super liberal, there’s people on all ends of the spectrum who are sponsoring and supporting this bill. Because I think it just does have that. It’s so bipartisan, it’s almost nonpartisan. Like it, like, really doesn’t seem to make sense to be against it. So I think that that’s something that’s, that’s going in our favor. And again, it’s one of those things that we get only by really trying to address a public health issue as opposed to like a personal, like, I just want to make life better for a PT type of issue.

Richard Leaver: And one last issue. I always say that we have to, as a profession, we have to demonstrate value. And this is probably the first time that I know of where not only will we demonstrate value, it’s actually going to be measured in a very methodical manner. So we can then go and reinforce the fact that we will save overall cost.

Nick Patel: Yes, and that’s one of the frustrations I have as I go through policy as a therapist. You know, I know every therapist out there knows that we save the system money. Inevitably you will treat a patient who gets to bypass surgery because of their interaction with you, or doesn’t need some injections or has now not needed to get 3 MRIs for the same issue. Whatever it happens to be, that saves the system money. Everything that we do right now that saves money gets rolled into the baseline. And by, by that, I mean we don’t get credit for any of it. I think we all know that if you just remove therapy as an option in the MSK treatment pathways, we would spend more money on all the treatment for MSK. But it’s hard for me to quantify that. It’s hard for me to show that through claims analysis right now. How so? If I create an entirely new physical therapy benefit that’s never existed in the system before and say, let’s just measure that we will be able to, if there are savings, which I’m confident there will be, we would be able to attribute all those savings to specifically therapy spent. And then the next time we try to get cut or the next time they try to propose, let’s see what happens. If we cut therapy. We’ll be at a point to, well, you know what, we actually do save money on this very high-dollar risk issue. If you have less therapists in the market, this will actually end up costing you more. I can’t really do that because right now, because all of our savings are sort of just used by other folks and, and, and absorbed into the system and we need to highlight and be able to break it out.

Richard Leaver: So talking about money, obviously the other topic that is re-occurring every year when it comes to advocacy and therapy is the Medicare rules. Kind of said in a deflated voice as well, I’m afraid. The 2026 Medicare proposed rule came out, I think a couple of weeks ago. Now I think we seem to be on a conveyor belt and of rate cuts and challenges to outpatient therapy from a reimbursement perspective specific to Medicare. And then perhaps we can open up the conversation to perhaps other payers. But specific to Medicare, are we still on this conveyor is the conveyor just chugging along, will continue to chug along for years to come where it’s kind of a death by a thousand paper cuts of, you know, know, 1%, 2%, 3%, or is there light at the end of the tunnel? So perhaps if we can just perhaps talk about 26 and then perhaps expand the conversation to a crystal ball and what’s going on from an advocacy perspective and legislative perspective that we can think about going forwards.

Nick Patel: Yeah. So I’m sure, as your listeners all know, you know, for the last five years, you know, we have been on this, you know, cut and then maybe we’ll get cut a little bit less and then, you know, but it’s still a cut and then we have to absorb a little bit more than next year. And if, if you accumulate everything from 2020 to about 2025, the therapy cut on the Medicare physician fee schedule has been almost 11% now that it’s all in and, you know, it’s sort of stopped phasing. One good thing is, so as we stand here, it’s the end of July, we have the proposed rule for Medicare for what the 2026 rates will be. They’ll be slightly higher than, than, than 25 rates. Not, not anywhere near the 11% that we have given up in, in the last five years. But I think from one aspect of the conveyor belt, I think we’re done with that sort of, you know, massive devaluation that we had to absorb over the last five years. However, having said that, we’ll see what gets finalized. You know, things won’t get finalized till November and we won’t know the exact rates till then. But what I have learned and that the conclusions I’m coming to recently when it comes to Medicare fee schedule is if you look at how the Medicare fee schedule calculates payments, it rewards certain things. Any payment system has inputs and any payment system rewards or weights certain things higher and lower than others. One of the things about, or just two things about the fee schedule that you have to keep in mind, one, it is a budget neutral pie, which means anytime they increase a particular code, there has to be a corresponding decrease somewhere else because the, the entire amount of money in the fee schedule has to remain roughly the same. You can expand a little bit without offsets. But you basically have to give when you get, whenever you get in one place or another. So most people don’t understand that. So there’s always little kind of shifts just owing to the budget neutrality but think about this: every time they create new codes and interject them in the fee schedule, the amount of money for the fee schedule does not change. So these ne new codes have to be valued and, and have prices attached to them. And then if they do that, then that means other things have to go down. And if you think about the, you know, progression of technology and care, new codes are coming in all the time. And especially, you know, maybe you went from the 90s to, you know, mid 2010s where the codes didn’t change much, but now you’ve got things even for therapists like remote monitoring, but for other physicians, telehealth type codes and technology assisted codes and caregiving, like there are all these types of things that are happening across all the different professions that are causing rebalancing of the fee schedule, whether there’s new money in it or not. The second thing you have to understand is what gets weighted. And here’s where I have some frustration a bit with being in the fee schedule. A good chunk of the weighting of what you get paid is how expensive your equipment is to deliver your care. And you know, if I asked, you know, you, Richard, like how many of your Alliance PTP clinics have a single machine that, that it costs a hundred thousand dollars. My guess is that you probably don’t have any pieces of equipment in a single clinic that costs a hundred thousand dollars. But that’s who we compete against. We compete against physicians who are having to buy $100,000 pieces of equipment or $50,000, you know, machines or, or what have you, and ours just do not cost that much. And, and, and then what will happen is that three years later there’s a new machine that’s invented and it costs even more and they have every incentive to buy it because then that actually becomes the increased waiting for, for them to put that in there. The second thing that can help drive your payment is what the risk is of the treatments that you do. So in other words, if, if the treatment by nature is risky and has like, higher malpractice, you know, threat attached to it, you get paid more as well because it’s a risky treatment. Well, again, therapists don’t get sued. Again, knock on wood. But we don’t get sued very often. The things we do are safe. The things we do typically don’t require patients to have a large risk. For, for the things that we do. There’s not much downside there. So if we’re in a system where the, in order to get ahead, you should have really expensive equipment or do really potentially dangerous things and then you’re going to see some nice increases. And neither one of those either now or probably never will apply to us. Are we in a system that we can never really win in? And to your point, are we in a, are we on this conveyor belt that you know, if every, if every dollar that is new spend has to come in has to be offset by something else and we really don’t have an increase in our equipment and we don’t have an increase in all malpractice, where does that leave us when these new codes or these reshifting has to happen? I think it leaves us on the plate to get cut more often. And I think that’s what happens. It’s my, it’s my two cents. I can’t calculate it out for you and show you the effect that that’s, you know, that it’s had. But I think as I look at if I, as I think about, you know, 26 and beyond, I think it’s time for therapy to come up with a game plan for how to get paid. As a provider that uses low-cost equipment, that does treatments that are not necessarily risky for the patient and carry large malpractice expense, is there a way for that person to get paid in a way that is commensurate with what the value that they’re providing but also is at the level of rewarding the education and the, and the knowledge that somebody has to put in there? And you know, when you’re in the efficient fee schedule. I hear this all the time. I am a DPT and I went to school for seven years and I get paid this. But you’re in a fee schedule with other, everyone else in that fee schedule has gone to school for seven, eight years. And so we, we don’t really win on that argument where the differentiators are the equipment and the malpractice and things like that. And that’s where we tend to tend to lose. So that’s kind of how I see our future is maybe our future becomes brighter if we stop banging our head up against the wall in a system that doesn’t reward low-cost providers that have high quality but low cost. That’s not necessarily what the fee schedule rewards. And I don’t think I’m going to be able to change the entire fee schedule. Maybe I just got to figure out a way for a therapist to get paid differently.

Richard Leaver: Yeah, it’s a pretty messed up system, isn’t it? Where if you provide high-cost, high-risk service you get rewarded for that. Whereas in reality why would you want to reward for that? Wouldn’t you one rather a society rather have low-risk, low-cost service. But anyway we can debate that.

Nick Patel: That’s why you’ll never find a physician that says no to let me buy an even more expensive piece of equipment because they’ll end. That’s how they actually get increased reimbursement.

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Richard Leaver: I Suppose the opportunity, I suppose we could just pay a hundred thousand dollars for a treadmill and just say we’re high cost. I’m not advocating our suppliers should listen to that.

Nick Patel: Yeah, please don’t. But yeah, I mean that’s, that’s in a nutshell, it’s sort of what we’re up against.

Richard Leaver: And then you know, you mentioned the kind of the 11% cut, that’s actual real cost, isn’t it? But relative cut to Medicare over an extended period of time. I’ve heard different numbers but when you take inflation into account as well over extended period, I think our relative cut has been again, correct me if I’m wrong, I’ve heard the idea is for approximately a 30% cut over the last five, 10 years. And I don’t know what number that’s kind of thrown out and used and you’ve heard. But it’s a significant cut, isn’t it? Compared to. Not compared to anyone really.

Nick Patel: Yeah, you’re, you’re exactly right. So you know the government publishes a number, it’s called, you know, MEI. It’s the index that sort of measures the amount of inflation for medical costs and medical care. Almost every other setting gets an MEI or a COLA cost of living adjustment upward every year. So for five years the fee schedule, not just therapists but everyone that fee schedule were not allowed to get any inflation adjustment. When that was originally passed it was sort of as a trade for getting out of the SGR problem which what we all, some of us remember was, was a huge problem. And at the time, inflation was very minimal. And so, you know, if you go back all the way to 18 and 19, inflation was not something that was a, that was a concern for a lot of folks. And unfortunately, people have a tendency to think whatever things are now is what they’ll be like forever. And as you, as you well know, things that inflation did not just stay at that level. It had been that level for a good number of years, but it eventually caught up to us and it spiked and it’s here to stay. And some of these price increases have been sticky and they show up not just in, you know, things like your, your equipment and maybe your rent, but it’s the salaries. I mean, you know, it’s, it’s, it’s, it’s the compensation for our workforce. Because I can make do without certain piece of equipment, but the one thing I can never make do without is the therapist. And, and again, you have someone who’s spent a lot of time in school and getting their training and the care a lot, and they coming out. I don’t think it’s a, I don’t think it was a coincidence that in the midst of all of this and during COVID I know it was a very tough time for every health care provider, but therapists lost 20,000 workers out of the workforce. That’s the equivalent of two years’ worth of new grads. And it wasn’t like they were just going to go on the sidelines and wait for Covid to kind of flesh out. They’re going to come back. These are folks who are never coming back. They have no intention of reentering the workforce, even though Covid has worked itself out. So it was, that’s why I say, I don’t think it’s solely attributed to Covid because they didn’t come back when Covid kind of resolved itself. And that’s the issue, I think partly is they found other things to do for compensation that why would I go back to being a therapist? I have found other things that keep up with inflation that allow me better upward mobility with my salaries. And that’s not just a Medicare thing. And I don’t want to put it solely at their feet, because I think we have a problem with payment off Medicare, Medicare Advantage, some of our commercial payers, you know, you name it, it’s across the board. But that’s what inflation also hurts us as well. So it’s not just that one-time purchase of a piece of equipment or that, you know, one time lease renegotiation. We pay our, we pay our people every, every week, every two weeks and we have to keep up with that. And, and, and you know, hiring new people every year with higher salary expectations than where than they had, you know, two years ago. It’s a difficult thing to manage. And again, we have to have a plan for that and we have to navigate that because there’s one thing right now that I’ve seen is I think that 20,000 workers out of the workforce, plus the fact that I think people do use therapy more now is we don’t have a volume clinic in most of our clinics. People are coming in, we don’t have people to see them, you know, and then, and we don’t get paid well enough on the people that we do see to justify bringing in more staff that can help. And that’s where the, you know, that’s where the real bane of our private practice owners right now.

Richard Leaver: Yes, I’m grateful the fact that I, I believe our advocacy is being heard and gaining some traction for multiple reasons. But one of the reasons which you’ve just highlighted is the fact that we as a provider are struggling to be able to provide any services for certain components of the community as a result of a lack of providers in a lot of geographical locations, a reduction in number of people applying for therapy school, relative reductions in pay over extended period of time. So it’s evident when you talk to APTQI members and in the broader outpatient therapy world that we have to change, not only change internally and perhaps how we treat and how we manage patients, but the reimbursement issue is becoming or has become, I think critical and ultimately it is the people who require our care that suffer by not being able to get the amount or even not be able to get care. So looking forwards, you know, from an advocacy perspective, what do you think? What, what is perhaps being done but more importantly is what can listeners, what can clinicians do? What can people supporting our profession do now? Because I think we’re on, I don’t mean to necessarily be melodramatic here, but I think we’re on pretty shaky ground and we have to get a footing and if we don’t, then I’m a little concerned that we won’t be able to continue to see pay the patients as the, we have this aging population etc. and increasing demand. So, so what can we do from an advocate advocacy perspective?

Nick Patel: Yeah, I’m going to throw out a couple things that might be a little bit different. This is usually the space where you may hear somebody say write your congressman and make a phone call or, or donate to a PAC. I, I feel like those pieces of advice are, they’re all great by the way, but I don’t think you’re telling anybody anything they didn’t already know. So if you’ll indulge me, I want to, I’ll say, I’ll say it for the sake of saying it. Those things are all important. However, let me, let me maybe attack it a slightly different way to maybe see if we can get better results. One is you want to write your congressman, call them, that’s fine. But think of it this way. Do you have a relationship with the elected officials office? And by that I mean have you ever just gone by their office? I don’t even does have to be the DC one. Every elected official has a local office in the district. Go by there and say my name’s Richard, I’m a business owner in this district at my clinic’s down the street, what have you. This is my business card. I’m a physical therapist. I’d like to be a resource for you guys to talk about anything as it relates to healthcare. If you ever want to know how something that you’re deciding on as it relates to healthcare affects us in, in the city or in the district, call me up. Or would you like to hear some examples of what I’m dealing with right now? That sounds really simple, but it doesn’t happen. And if you think about this, there’s 535 elected members of Congress, right? If that happened 500 times in every district, I think we’d be getting a little bit different. I just, it just right now it doesn’t, it’s, it, you know, advocacy is a one time a year. Let’s all go to the Hill, let’s make a rounds and then we’ll come back home and the other 364 days are just griping about how things really don’t work well for us. What I’m saying is go locally, become that person, go there multiple times. Advocacy is not a one time a year thing. You know, if you want to get paid every day for your services, advocate every day for your services. If you want to, if you want to make your payments every month, advocate every month. So I mean you go there and you make relationship because guess what? The guy who’s working there who loves you and thinks you’re great and wants to form a relationship with you where you have this – great, great. Understanding will be promoted. And out of that, and then you got another one, you gotta start again. And that’s what you do. And you keep going back because there is a lot of movement with those jobs. So create a relationship with them. It’s not that hard. I tell therapists all the time. Every therapist I know that worth their salt, have this innate superpower where you meet someone who is a complete stranger to you and within five minutes they are taking off their shirt and pointing to where it hurts. They are. You can make someone incredibly comfortable with you who is a complete stranger. If you cannot walk into that office and say, I’d like to talk to you about physical therapy and what it means and how these things affect us and my employees and my patients. If you don’t feel comfortable doing that, I don’t know what to tell you. You can do something infinitely harder than that every day, sometimes 12, 15 times a day. Can you not really do that? I don’t believe it. I refuse to believe that. We’re not good at that. You don’t need training. You don’t need, you know, a whole lot of guidance and mentoring. You probably do it tomorrow if you really want to. So that’s one thing. Create that relationship. Second thing, if you’re a business owner, I’m not going to tell you what to do with your business, but maybe my advice would be think twice when you get that contract and the rate on it is so far below what your cost is to provide that service. And I would just say think twice about, you know, signing that. You know, again, everyone needs to do it what they need to. But I think there’s something to be said for every rate that someone complains about is a rate that someone signed, though. So you know, that. It’s definitely not our – I’m not saying it’s our fault like it’s – The insurance company is setting a rate. That’s what they’re doing and they’re doing what they think is best. I’m saying maybe you should do what you think is best for, for you. And at a time when volume doesn’t seem to be an issue because we are having more boomers and we are having more people come into our clinics. Just take a second to look back. It is a form of advocacy to say, I, Richard, believe I am worth way more than $65 a visit. You are advocating for yourself or your therapist to say that this is not a fair price for what I do, it does not reflect the value of what I provide. And I know that it could be a difficult thing to lose some patients if you have to. I understand all that and those are parts of the equation that are not easy. But my request is if, as you’re thinking about advocacy, think about it, whenever that next renewal comes, the last thing is probably something. Again, it may be a little bit, you know, out of, out of left field. But again, there is voice, there is strength in numbers. So you know, it’s what alliance did. You don’t, if you don’t like APTQI, try to get involved in APTA. If you don’t like APTA, find another NARA, like whatever it happens to be. I think so many of our, of our folks say I don’t want to advocate because I don’t like this association. Yeah, I don’t. And it may be all valid. Maybe you don’t like decisions they made, maybe you don’t like the people that are there. I, it’s fine, whatever. But then just find somewhere else to join in and amplify your voice. I think right now there are more options for the therapists out there to join with like-minded people than ever. So it’s okay if you don’t like our group. That’s fine. If, if you know, if you’re an OT and feel like APTA has nothing for you, how about AOTA? Look at them, whatever it happens to be. But I feel like there is more avenues today than ever and there’s less excuse for you to say I’m going to tune out and not lend my voice to a larger group because I have maybe some philosophical differences with that group. Valid, fair. I’m not going to argue with you if that’s the case. But then there’s got to be somebody else, you know, that does seek those people out. Whether it’s a conference or meetings or whatever. Something tells me you’ll be able to find someone that you say, yeah, I think this, this is worth merging my voice into because we cannot sit back and say, well, I don’t like that group so I’m kind of not getting involved. Find another one.

Richard Leaver: Yes. And then the world of social media as well. It’s very easy to put one’s voice behind advocacy. And it amazes me how much traction certain very simple media, social media posts can get and they can get picked up very easily by multiple groups, multiple individuals. So I think that’s another method that if we get sufficient numbers that are proactive in that can be extremely powerful. I’d love to see some PT influences focused on the advocacy component. I don’t see any or hear of those, but there’s absolutely no reason why there shouldn’t be those people, should there?

Nick Patel: Yeah, no, exactly. And if you think about the numbers, I mean, one of these things, it’s almost a great trick that’s been played on therapists. And I see this happen a lot when I talk to folks and they always say, well, we’re so small, we’re always going to get picked on or we’re always the little guy. We’re like, we’re always a very fraction of a fraction and blah, blah. There are hundreds of thousands of therapists in this country. Right. Granted, some of them aren’t full-time. And I understand that that’s an inflated number for a lot of reasons. But my point is there’s more of us than a lot of other professions. There’s more of us than a ton of other professions that get a lot of what they want, whether it’s in Congress or for private payers or whatever. But sort of I almost think like I always feel like someone has been sold a bill of goods to be told we’re just too small. We really can’t get anything done. If we band together and create some volume behind our voices, we can actually get quite a lot done. Because if every profession spoke with a hundred percent of their licensees, we wouldn’t be near the bottom. We would be. Not even in the middle. We’d be closer to the, you know, the top quartile. You know, there’s way more of us than chiropractors. There’s way more of us than, I mean, a lot of the people that would probably surprise you because there’s just a ton of therapists out there. But yes, we all have a lot of us. We work in a lot of different settings and we work in a lot of different, you know, practice especially areas. But my point is we’re not small and don’t let anyone tell you we’re small and don’t let anyone tell you that we’re just a fraction of a fraction of a fraction. And we. So therefore, what’s the point of trying to advocate. Because we’ll never get what we want if everyone spoke up or found a place they felt comfortable to speak up. I wish it was with us or with APTA or. But it could be with anyone. Doesn’t matter. We will actually get a little bit further, stop believing in that because I don’t think it’s true. It will. The numbers don’t. The numbers say it’s not true. Yeah.

Richard Leaver: Time’s always against us with these conversations. It’s been great. Any final thoughts, words of wisdom, perhaps to our listeners? And then also, if we’ve talked a lot about the aptqi, how would somebody learn more about that group as well?

Nick Patel: Yeah, if, you know, if you’re a provider and you have, you know, you have some clinics and you want to learn more, you absolutely can go to our website to learn more. APTQI.com – you can email me. It’s NPatel@aptqi.com I, you know, I respond to as many emails I can directly. The last thing I leave anyone with is don’t despair. And because it can be a dark time to be a therapist and practice owner right now, whether you’re a staff therapist or you’re in charge of, you know, multiple clinics. The five years that you just went through were probably quite difficult. And you may feel like you have a bunch of train marks down your back and, and, and, and that’s valid for those of us who are a little bit older. I can only say 1999 and 2000, 2001 were very similar, if you’re my age. And there was a time where we thought therapy would never get better and it was very difficult and you couldn’t find a job and you couldn’t get reimbursed, and it didn’t seem like there was much of a future, but there was. And actually things ended up leading to a quite of a boom time for therapy. I truly believe sometimes things are just about to be the brightest. Right when you feel like things are the darkest and can’t get any better. So don’t give up on the profession or don’t give up on what you’re doing, if you are advocating. Because typically, whenever we are pushed up against the wall, things start to get better because we as a profession start to fight a little bit more. But also, you know, the pendulum can only swing so far in one direction before it has to start swinging in the other. And you don’t want to miss that ride. If you’ve hung in here for those five years, you don’t want to miss the ride going back the other way is sort of what I’ve been trying to tell people.

Richard Leaver: That’s remarkable wisdom. So thank you, Nick. And some from somebody who’s only 25 years old as well.

Nick Patel: So yeah, yeah, I just read about 2000 in history books. Richard.

Richard Leaver: Well, again, thank you. Thank you so much for what you do, Nick. And thank you so much for what APTA does, APTQI, and the other groups that advocate for therapy, because we’d be in a much different place if we didn’t have all of you. So I appreciate you and everything that our profession’s doing to help drive us forward. So appreciate it.

Nick Patel: Appreciate you having me.

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