Financially Feasible Care: Overcoming Monetary Barriers in Physical Therapy with Jarod Hall

Welcome back for another episode of the Modern Pain Podcast. This week is a reunion episode, as I got to sit down and speak with my bud and former co-host, jared Hall. We chatted about the need for physical therapists to transition from being more revenue generators to really crucial cost savers in the healthcare system. We're gonna explore some side programs that offer counseling and education as alternative income streams and highlight the role of physical therapists as health quarterbacks for patients. Jared speaks to the importance of collecting data to prove cost saving benefits of physical therapy over time, emphasizing that immediate financial gains shouldn't be the sole focus of us trying to better represent ourselves in healthcare. We discussed the untapped opportunities in lifestyle and wellness services for physical therapists, including examples like fitness and wellness programs. And, lastly, jared and I get into the systemic challenges we face, particularly in the US, that make it difficult to implement cost saving strategies on a really large scale. It was great talking with Jared and this episode will give you some ideas of how we can tackle some of the financial challenges we face as a profession. Enjoy the episode.

This is the Modern Pain Podcast with Mark Karjula.

Welcome to the podcast Jared Hall.

It's good to be here, man, just like we were talking about before we went online. It's been a minute since we have jumped on one of these calls. We used to do it all the time and have a regular touch base, but I've still been following along on the podcast, listening to all these really good interviews you've been doing. So I'm glad to come back on for a little bit of a reminiscing session.

Yeah, you know, when we kind of stopped doing it together, it was interesting. I don't know how you were, but it was. I was feeling questions like did we have a messy divorce or something like that, where it was just some sort of ugly situation where we just had to part ways or things like that, and it literally it was just a burnout situation for me and, I think, a little bit of the same for Jared, as far as just like we needed to step back, catch our breath, regain some footing and some prioritization in life. And thankfully we both have. We've chatted before this, we'll chat here on the podcast that you know. Things are going well and life's good on both ends, so we're happy to have you back, man, it's, it's. It is something that where we were, you know chatting on a pretty much two to three week basis, you know, wrapping up, you usually just would crunch out three to four episodes at a time and then have a little month to just kind of catch our breath and then get back at it each month. And yeah, it's good to have you back. Now you're a little bit still in the clinic. I know you're teaching still a bit, but you've you've taken more of a role in the management aspect of our profession and I've seen you, seen you share content on you know that perspective and seen things from that view. Because I would agree with you and others that there's a little bit of a lack of understanding from a just definitely new grad physical therapist even existing PTs on what it means to run a successful practice that allows folks to have the benefits and all the things that we all want as physical therapists. I think there's a little I know there was for me a little naivety of the whole situation. So I love if you could just kind of discuss maybe what your role is now and what you're up to overall and then and then maybe just kind of touch upon your perspective and how maybe it's shifted, as you've kind of seen yourself move into some of this more still still still talking to some patients but obviously doing a little bit more on the management side of things. I'd love to hear what your perspective has been with that role.

Yeah, yeah, you know I'm pretty fortunate right now at least I get to have some diversity in my life. I get to treat patients about eight hours a week, work with patients on average, sometimes a little bit more, sometimes a little bit less, sometimes a lot more if somebody's on vacation and I really need to step in and cover their clinic and that sort of thing. I'm in the thick of teaching at the local PT school right now in their orthopedic curriculum, so I always help in their orthopedics one, orthopedics two, or what we call MSK one, msk two. Now I get to help a little bit in their business course here and there and do a little bit with therapeutic exercise. So that's always fun. But then you know, the main thing that I'm doing on a day-to-day basis is I oversee about eight clinics, oversee about 1,500, 1,600 patient visits a week, a little probably 30, 30 therapists I can't really I don't know the exact number off the top of my head. So I am doing a lot of management and mentorship on operations of clinics and looking at P&L spreadsheets and understanding trends that are driving positive business growth or expansion of a clinic and that sort of thing physician relations, things that are not going well, from clinic culture to clinic efficiency to patient experience, helping therapists and clinic directors understand that and see what really makes us profitable or keep the ability to maintain providing salaries and benefits to people and to keep the doors open and all of that sort of stuff. And trying to find that little sweet spot, that little area in the middle that makes people happy, makes a firm clinic, makes an effective clinic, isn't a mill and doesn't sell your soul out but still is profitable and you're able to keep your doors open and all of that sort of stuff. Or payout bonuses here and there. And it is a tightrope, it's a balancing act. It's really interesting Some of the stuff that I have learned over time and how much I have come to understand that the average person, the average therapist, even if they've been a therapist for 20 years, might not have any clue what this stuff looks like on the back end and what's relevant and what's important and what's not and when it comes to maintaining a profitable or decent business. So it's just been a heck of a learning experience for me over the last couple of years to really get elbows deep in understanding what this stuff looks like.

I was talking with you before when I did some clinic directing work. It was interesting to start peeking into P&L statements and budgeting and all the things that go along with it not to the extent that you're doing it, but as I look at the social media landscape and see a lot of like new grad PTs or student physical therapists who are talking about some of their expectations rolling into the profession, and then I'm like I admire the expectations but sometimes I wonder if there's a little bit of a utopian view of for students and even some early career professionals who maybe don't have that footing and that understanding of whether we like it or not, we have to be fiscally responsible as businesses to be able to maintain, like you said, paying salaries, given benefits, vacation time, all the things that we all want. But sometimes I think expectations versus reality of what fiscally we are able to do can be two different things. I'm curious what your experience has been and what you've seen out there as far as the because I've seen you posting on it a little bit as well of what students and early career professionals are talking about, what they expect and what they think they deserve coming into the profession, and then what the reality is of what you see sometimes out there.

Yeah, you know, a lot of times you know what what students expect, or you know new grads expect and what is, you know, possible and what is realistic are not always super close together. I would say in general, you know, I think that there's been a dramatic increase in starting salaries and that sort of thing over the last couple of years, heavily, heavily driven by inflation. And you know what I what I do have to say is the things that I talk about are in the Texas market, in Dallas, fort Worth. These are markets that I understand well and you know there are other markets that I don't understand as well but have some knowledge about some other states and things like that. But there are plenty of places that could be very different than what I'm saying and that's also just the reality of the situation. There's regional differences on costs of living and what insurance companies pay for physical therapy and all of that sort of stuff. So you have to take into account that the things that I'm saying are for the markets that I know, so they could vary a little bit. But in general, you know, with inflation, with all this stuff that's gone on over the last couple of years, it's made running a business a lot more difficult because all of a sudden insurance companies don't pay any more but the cost of running that business has inflated about 10%. You know, if you look at commercial real estate and you look at the salaries that are being demanded and you look at the cost of providing benefits and that sort of thing, all of those things have gone up. But we don't really have the ability to set our price very easily in the medical profession, in physical therapy. But we do negotiate. You know we try to negotiate with insurance companies but almost never do they say, yeah, we'll pay you 10% more for this thing because it's gotten more expensive for you to run your business. Most often they're saying, yeah, we're going to pay you less this year. Sorry, bud, like we used to give you 12 approved visits and now you get six approved visits or whatever it is. And you know, anybody that's listening at all knows that every year Medicare tries to reduce how much they pay physical therapists. They're always trying to cut us by two or four or six or 12% or whatever. They're always trying to cut us. And we have to go and negotiate and we have to go and scream at them and pick it and all that sort of stuff and say don't cut us. You know, I know that you have a balanced budget. You got to cut somebody else. You got to take that money from somewhere else and don't take it from us, Otherwise we're just not going to be able to see your patients anymore. So that's a real interesting phenomenon. That goes on and when I would say more often than not when folks are coming out of school, they're early career professionals. They have a mix of desires, but the number one, the top few desires that I see, are, first and foremost, people want mentorship, and you know what does mentorship look like? A lot of people aren't you know really sure what that should look like for them. They have this idea that, hey, I want mentorship, I'm a new grad, I'm scared to just be thrown in here. Well, you need to talk to an employer about what does mentorship look like? Does that look like they pair you up with somebody, that you have their personal cell phone number and you can call them, you know, at any point in time and you can bounce ideas off of them or you can get feedback. Does that look like formalized mentorship in a clinic where, you know, once a week or once every other week you get to treat for an hour or two with another therapist you know? Does that look like a virtual program that is, a cohort of students, that, or a cohort of new grads that kind of get put in that together and they have monthly touchbases? There's a lot of different ways to do mentorship and people almost invariably say man, I want to have a little bit of mentorship, I don't want to be thrown into the fire. In general, everybody is saying I want to treat patients one-on-one. You know, I want one-on-one time with folks and that's also something that they need to get clarification on. Because what does one-on-one mean in your book? Does one-on-one mean I want to treat, you know, 80 patients a week for 30 minutes and I want to see each one of those patients for 30 minutes. And you know, I see somebody at seven and then I see somebody at 7.30, and then I see somebody at eight and then I see somebody at 8.30. Does that look like I want to see 40 patients and I want to see every single patient for an hour, with no overlap with other patients, and things like that, or does that look like? Well, you know, I want to see, you know I'm okay seeing 60 visits a week and recognizing that that is an average of 12 visits a day, and there will be some time where I definitely have patients that I can treat one-on-one and there will be some time where I have patients that are maybe a little bit overlapped with each other two folks that are eight weeks after a knee replacement and it's super cake to treat them at the same time, versus I have the flexibility on my schedule to designate folks that I want to see one-on-one that I think need my full, undivided attention, no matter what. So that can look a lot of different ways as well, and you know the company that I work for. We kind of fall in that last scenario that I talked about. Our expectations are hey, we want you to see somewhere between like 54 and 60 patient visits a week, and I would say that that is middle of the road. There are plenty of places where you will see more than that. There are plenty of places that you can go and see less than that. But you have to factor in what is my salary, what is my benefits? You know, what is my ability to bonus, what are all these other things? Right, because in general, what I'm telling students in new grads now is that no job is perfect. You have to pick what type of not being perfect that you're comfortable with. You know, is money first and foremost for you, or is flexibility in schedule, or is one-on-one patient care, or is, you know, really good benefits because you have a family and you need health insurance and you need good 401K? Is it a great continuing education budget with mentorship, like what is the flavor of not perfect that best suits you? Because you just literally are not going to find a place that can provide you all of those things, because all of those things cost money and their margins are very, very thin in the physical therapy world. So for us, we like I said, we do that 55 to 60 visit range a week with the ability to designate, you know, any patient that you really need to see one-on-one. You classify them and say, this person, they've got some complex stuff going on. Man, I cannot handle seeing them with another person. But then you say, hey, well, I got two guys that had their knee replaced eight weeks ago. They're crushing it. They have no, you know, comorbid conditions. They have nothing that's worrying me. It's actually fun for them to come in together because they like to hang out and they like to shoot the shit and those two dudes. It actually creates a better therapy experience for them to be in with another patient because it's almost like you know a workout buddy or something like that. So you look at your schedule and we encourage our therapists to have a lot of control over their schedule. We have the ability to take that control and some therapists do that. Yeah, I want to schedule my own patients because I want to know who's coming in when and at what time, and who may or may not be overlapped with another person Other therapists, that I don't care. Well, I'll let the front office take care of it. My front office manager can schedule folks however they want to do it. So you know again, that's me speaking to my area but they're in the Texas. In the Texas world, in the private practice world, it is not uncommon to have clinics that see, you know, your expectation is to see 70 or 80 visits a week. I know some private practice owners that they see 90 to 100 patient visits a week themselves and I've gotten to where I don't say negative things about that any more like I used to, because I understand now how difficult it is to keep your doors open. And some of those folks that that guy that's running his private practice by himself he's seeing 90 visits a week. I guarantee he doesn't want to see 90 patient visits a week himself, but I guarantee you that he has to to pay for the things that he needs to pay for to keep his business open and to get him to the point where he can hire a second therapist in that sort of thing. So I used to say, oh, that is just God awful and all that sort of stuff. I don't say that anymore because I understand how difficult of a position that those folks can be in. So I'll stop right there because I've been just kind of talking about a lot of things, and I'm sure you have some input or some other questions you want to ask Mark.

No, I think you bring up something like I just can reflect back, like coming out of school, like I'm only seeing people one on one, nobody's going to tell me to double book. And then I've seen the same thing you know happen clinically where, as it's been happening in clinic and I've been open to double booking once, my ego and my fragile ego was okay with it that all of a sudden I'm like man, there's a lot of people who really dig this environment where there's another person with them and they're really kind of in this together. They're kind of sharing some of their stories, they're kind of showing that they're, you know, kind of pushing each other along and things. So I think it can be done well. Now, obviously, you don't need to in certain instances and like having the flexibility, like you said, where some folks probably do need one on one care and some, you know, one on one ear time to be able to listen and validate and what's going on with people. But yeah, it can be done. Well, it is okay to see. You know some folks. You know that might overlap a little bit, but there's some folks and I get. I used to be this person where, oh my God, that's horrible. You should never do that. But again, I think there's definitely ways you can do it well and you guys are obviously doing it well. I'd love to hear, because you're seeing things obviously in the Dallas-Fort Worth market. So again, it may not always apply. I think Phoenix is somewhat similar, but the challenges you see out there as you're kind of seeing things down the road as far as are there any storms brewing on the horizon that you are I've seen you post some discussions about this and we don't have to be doomsday. There's a lot of good things to think about. Here in PT we have a privilege of helping a lot of folks and still a relatively healthy profession. But I'm just curious what storms you see brewing on the horizon as you've been able to kind of see things more big picture in the profession. Oh, man.

Yeah, we can talk about a few things. I would say the number one problem that I see right now. Well, there's two main problems and they both deal with money because, ultimately, none of us are doing this for free. Nobody wants to go treat patients for 40 hours a week, 45 hours a week for free. So insurance payment for physical therapy care if you look at a chart over the last three decades you will see that that number has stayed the same or actually gone down a bit. So I was talking to the owners of my company the other day and they said, hey, when we started this business in the 1990s we got paid about $97 a visit for physical therapy. Now let's fast forward 30 years and we're averaging about $90 a visit for physical therapy now. So you've gone down $7 per visit in 30 years. But inflationary pressures, the cost of running that business, the salaries that people want, the cost of providing benefits, has gone up astronomically. And if you just take your little normal 2% inflation year over year, the Fed tries to target 2% inflation. This is why annual raises just standard merit increases year over year, are usually in the 2% to 3% range. You're given that merit raise to help keep up with inflation, right? We're assuming everything is becoming 2% more expensive year over year. So we need to give you 2% to 3% more money to both keep up with that and if you do a great job, maybe you get 4% or 5% of a raise or 6% or whatever it is. If you're crushing it, you've proven yourself to be a great employee, a great therapist, so on and so forth You'll get a raise over what that standard inflationary number is. So if you look at just inflation 2%. If what we've been paid or what we are being paid for physical therapy had increased at normal inflationary rates that 97 for 1990 should be about $160 a visit, now $164, $5 a visit. So if what we've been paid increased at the same rate of run, if that number had increased at the same rate as the cost of running a business, we would be getting paid $160 a visit. And we're just not. We're being paid less. And that's wildly different across the board for different insurance companies and that sort of thing. Because I know in Texas Blue Cross Blue Shield is a great payer. They pay us pretty well. If you see a person with Blue Cross Blue Shield you can easily get paid over $100 a visit, $110, $115, $120 a visit. But if you go across the state line into Arkansas, it's my understanding that Blue Cross Blue Shield is one of the worst payers in Arkansas and I don't know how it is in Arizona. But you see these differences. So Blue Cross, blue Shield, helps save us a little bit in Texas, because you've got folks like Cigna that in Texas only want to pay $59 for a physical therapy session and I can tell you that people want to make. You're like, I've got a doctorate degree, I want to be making $50 an hour or whatever it is, and there's not a lot of room in there if you're getting paid $59, but you get paid $50 and you've got to run your business and you've got to pay for support staff and you got to pay for utilities and so on and so forth. So it's interesting on those margins and that's why a lot of folks don't accept certain insurances and that sort of thing and ultimately it's patients that end up suffering as a result of that, because if their insurance doesn't pay, worth a darn well, they have to go to the only place that will see them and that place likely is running at a very, very high productivity expectation because they're seeing they're getting paid so little. So you've got to be partnered up, you've got to be double booked or triple booked to make that hour even financially viable for that business, because a business just you know you're not in the, you're not in business to lose money. So that's the number one problem that I see in that we've got to do something about, we've got to get creative about, we've got to somehow figure out how to change the way that insurance companies value what it is that we do. And then the second problem is the cost of education has gotten pretty darn high. In particular, if you're not able to go to a state school, if you either choose to or only accept it into a private school and they have a very high tuition and you have to take out student loans to do so, being saddled with a really high debt, you get out of school and your monthly debt payment is $1,000 or $1,200 a month. That's really difficult because what it ends up doing is it forces people coming out of school to choose to work in settings that maybe they don't want to work in, and then they can never, they can never really change or they can never go back. You have to go into travel therapy because it pays a lot. Even though you don't really love the weird scenarios you get thrown into, it's hard to stop doing that because you're paying off that debt. And then, when you do pay off that debt you're like, well, I don't want to take a big pay cut to go work in an outpatient clinic that I would really like to work in. I don't want to do that because I'm used to this much money coming in. Or lots of folks end up in home health and that sort of thing that maybe didn't really want to be at home health. That's where you can get paid really well. So there are some interesting things there and the cost of education with how much we get paid. I think that I don't know if it was the APTA or not. It might have been the APTA. There was a study that was done a couple of years ago that showed the return on investment for the physical therapy degree has crossed the threshold to where it's not really that good of a return on investment based on the average debt amount and the average salary nationwide.

Yeah, now you're definitely hitting some topics that I would definitely agree with you on being part of higher education and seeing the debt load that students are coming out with. It's tough man and I honestly I've had discussions. If my daughter came to me 16 years or so from now saying she wants to be a PT, in this current climate I'd have a hard time is if that was her passion and what she wanted to do, then I would fully, 100% support her. But as long as she was fully educated on here's what you're getting into, obviously we'd help her financially as best we could as a parent. But here's what you're getting into and here's what the return on investment is and I just think we have some work to do as a profession. I know there's some things beyond our control with politics and our lobby doesn't have the power of the other lobbies out there that are spending Udall's more dollars to influence political things going on. But yeah, it's a tough situation. And then you got grads coming out where they're choosing finance versus career development, which I get it. I don't blame anybody if they want to do home health or travel PT to kind of offset, even though their heart might be in God if I could get in an outpatient situation where I was getting some serious mentorship, now realize mentorship costs and like to have somebody mentor you. And this is something that I was fortunate where I chose mentorship versus a high salary early on because it gave me a lot more ability to then push for higher salary down the road when my skills were at a better place and was able to garner a lot more respect in the patient community to where I had some value to bring to a company because I had a decent referral base and things like that. But yeah, it is a tough situation out there. I think there's still good things to say about it. It's not obviously a doomsday scenario but hopefully we can figure out some ways to find some ways the insurance companies, like you said, can value us more and give us some more reimbursements to justify I mean, obviously we can show we have enough data to show conservative care versus a lot of expensive care. Really comparable the fact that to get an opioid prescription it's so freaking cheap in this country. Yet to get about a physical therapy covered, to get a $250,000 multi-level fusion procedure covered, versus a 12-bolt visit of physical therapy. It's just there's a lot of broken things in our system that I'm sure I'm preaching to the choir with you and to a lot of folks that are listening. What else can we talk about, man? There's a lot of things out there. Any other thoughts you have that you wanna roll through?

Yeah, I mean, while you were speaking there, the only thing I could hear was the people that are gonna listen to this and say, well, that's why you just don't take insurance, you don't want to a cash-based physical therapy clinic. And let me teach you how to start your own cash-based physical therapy clinic. And a lot of those people need to be kicked in the shin, to be honest, because, sure, a cash-based physical therapy clinic is the best If you can charge people $150 to come in and see you and you can see people one-on-one and you can fill your schedule up with 35 to 40 patient visits a week. Yes, that is awesome, yes, that's phenomenal. But the reality of the situation is that is only viable for a very small percentage of the population that has that expendable income to be able to pay cash for your services. A lot of people, even that do have that expendable income, will say I also pay for health insurance. Screw that, I'm gonna go pay a $25 copay at this other place down the road. I'm not gonna pay you $150, even if maybe you are a little bit better or whatever it is. And then let's talk about just demographically in demographically, geographically across the nation, that cash-based physical therapy clinic can only survive in certain areas. It can only survive in certain zip codes, it can only service so many people, and the rest of the folks in the world have health insurance and they need to go to a clinic that takes their health insurance and they need to get care provided to them in that model. So while, yes, I think that those cash-based physical therapy clinics are wonderful, everybody can't do them. Period. Everybody can't do that. That market hits saturation pretty fast, depending on where you're at. So I have to throw that out there because I'm pretty tired of seeing new grads and stuff like that. People come out of school and they're sold a story on how they can be successful and make so much money doing their own cash-based practice and this, that and the other, and then a year later they've A. They've had a year of not making very much income. They've had a year of putting their loans into default. They've had a year of dumping money into a business and marketing a website and things like that, and it doesn't really pan out and then they just have to go, they have to close up shop. I'm seeing this on a regular basis. We're a larger company in the DFW area and in Texas and we have private practice owners literally calling us all the time saying can you buy me out Because I can't make a profit anymore. This is really tough. I'm tired of 60 hour weeks. I'm tired of scrounging and scrambling Like it's not profitable for me anymore. Will you buy my clinic? And then we have to look at it and run financials and say, not really, dude, we're not gonna make any money on your clinic either, so we can't just give you money. Or they say like oh man, I've put blood, sweat and tears into this and I think my physical therapy clinic is worth a million dollars. Will you pay me a million dollars? And then we look at it and we're like well, your EBITDA is about $30,000 a year and we can pay you a five times multiple on that.

So we can pay you $150,000, not a million dollars.

I know you value it a million dollars, but the reality of the numbers say that if we paid you a million dollars and you're only making $30,000 a year, we're never gonna make our money back on this Like it's gonna take two decades to make our money back on this. But if we pay you a five times multiple, well, we can make our money back in four to five years and then that becomes a little bit profitable for us. At that point it becomes a net positive on our portfolio rather than a net negative. A lot of people don't really recognize that.

Yeah, no, I echo your sentiments on the cash-based craze. I do think it's a model and if somebody really does their homework, understands economics, understands some of the socioeconomics of the area they serve or they want to serve, and they make a good, educated decision versus this, like you know, utopian lifestyle of you're making all this money you don't have to treat all the time and it exists, I mean, but it exists, like you said, in places that can support it and I do think that it comes with a lot of business and marketing chops to be able to show significant value and to be able to do good in sales, which you know a lot of folks get, you know, especially PTs. We cringe to even hear the word sales, yet we sell every time we're trying to get somebody to commit to applying to care. It's just, you know, without the insurance, let alone with cash base behind it. So I think you know, I agree, I think sometimes it gets pushed upon folks and I've also seen folks who've gotten sold the cash base fantasy and again, it doesn't have to be a fantasy. If you do good homework, you understand the reality of what you're getting into, you understand that. You know you need to do your homework to make sure you live in a economic area that can support such a clinic, then knock yourself out and crush it. I mean, I think Jordan and I would both root up heavily for you to do it. But just buy or beware on a lot of that stuff. As far as make sure you understand a lot of what goes into making one of those practices work and yeah, it is rainbows and butterflies sometimes when again, and competitions out there. There was a point in my life, you know, probably even five, six years ago, where I was like I'm just going to start my own thing, and then it was having these discussions with folks in your situation and private practice owners who are burning out and all these things. And there are some folks who are crushing it and doing well and loving life. And you know it's on not by all means saying this is what everything, but I think there's some sobering realities that we just need to be aware of that you know, do your homework, understand the finances behind what you're doing, even as a staff clinician. I think it's helpful to just talk with your manager of like I'd love to better understand what goes into. You know the financial runnings of the clinic. I think it helps you as a physical therapist understand some things. If you have aspirations of being a clinic owner or a clinic director, it helps you start navigating your way up that ladder, maybe within a company like Jared's, where you start showing an interest and managers notice that and they say, hey, this person's really shown an interest and that might be your way to kind of climb up the scale a little bit and earn yourself into a better salary and more managing capabilities. But you can also be a great clinician too. You can treat patients, you know and see a productive schedule, have great reviews. You know your productivity, which I think your company sounds very realistic. You know I'm not hearing. You know three or four people quadruple booked and all these things I think appropriate use of your census and you know keeping patients at the center. I think you can still have a great career and a very satisfactory career. But I also to kind of circle back to your education thing. I know we spoke about it already. I think there's some challenges out there with how much tuition is where that's heading as well. I think if you look at that same graph, you speak of what reimbursements look like over the last 30 years again, how much inflation and things are and how much tuition has changed Got. When I came out my debt load and I was pretty aggressive, taking loans out because I was, you know, typically responsible as taking loans out to go to frickin spring break, for God's sake I came out with like 40,000 and I thought that was like a monumental, you know, mountain to climb and I'm and now I hear folks where it's like five, six times that coming out of school. It makes me like just get like ill in my stomach to hear that that's a large load and some folks are doing amazing things paying that off. But man, we do have some challenges ahead of us to kind of hopefully reform some things and but we still work in a great profession I won't get us to down in here and we have a great opportunity to serve some folks. I think I'll be interested to see if there's ways, especially with the way we can get in front of patients and get our message out there. I just wonder how much I'd be curious your thoughts to on this Jared, as far as how much continue to beg for the scraps from you know insurance companies and different things like that versus you know and then trying to lobby towards physician groups and things. I'm not saying those aren't. We shouldn't do that, because those are obviously important initiatives and we need to maintain that. But I'm just curious if you see any emerging models or many ways that we can maybe get our messages out to the two directly in front of patients or do some things to maybe start being creative with our ways of delivering services versus the traditional you know beg for insurance companies who over the last 30 years haven't really shown any signs of moving in a positive direction for us. What are your thoughts?

Well, I mean in general, and I know that this is, this is pie in the sky, but we have to step into a role of not only just rehabbing people who have pain and or are injured or had surgery, but being like stewards and champions of actual health. And I think that the reason that insurance companies pay physical therapy less now, the reason that we're in all of these problems, the reason that you know Medicare has a balanced budget but they still have to continue to lower what they pay, is because the United States in particular is very unhealthy. We are not a we're not a healthy population. We spend the most on healthcare but we are like number 19 or 20, are all the way down to number 70 of you know number of how good we are on various health outcomes, and that is primarily driven by nutrition, lack of exercise, lack of movement, you know, being overweight, being obese, metabolic dysfunction, so on and so forth, paired with longevity. Life lifespan has increased. You know in the last 30 or 40 years, how long, or last 50 years, how long the average person lives has gone up. So now, when you get really sick and unhealthy at 55 years old and let's say 50 years ago, let's just call it how it was you would have been dead by 60, you're now living to 80 because modern medicine is keeping you alive. Medications and surgeries and all of this sort of stuff is keeping people alive longer. They would not have necessarily been able to survive before we had these advancements. What does that lead to? That leads to the health care system or insurance companies having to pay for very expensive care for a very long time while people live with, you know, very chronic and debilitating diseases and conditions. That costs a lot of money. If we, as physical therapists, could step into being health care providers that mitigate some of those costs and we could justify to the system hey, if people see PT once a week or once every other week and it's like a maintenance thing, it's like thing where we're a health coach and a movement coach and an accountability partner and this and that and a resource for education on all things health and pain and injury and all of this sort of stuff and we're saving the system boo-coos of money, we should be able to reap the rewards of that. So in my opinion, I would love to see physical therapists go that way, as health care providers that, of course, rehab people and, of course, see people after injuries and surgeries and stuff like that. But we also become this general steward of and we'll say, you know, quarterback of a patient's health right, a person's ability to minimize how much metabolic dysfunction that they get into a person's ability, a resource for minimization of over medicalization of normal injuries and pathology and things like that, because we all know that you know, you see these pathological changes in a person's body over time that may or may not correlate super well with the pain that they're experiencing. And they go and get an x-ray. Because if you go to the primary care doc, the primary doc is going to order an x-ray straight off the bat. They're going to get that radiologist report that says destroyed spine syndrome and then when they get destroyed spine syndrome they're going to be sent to the surgeon. And you know there are a lot of great surgeons but there are a lot of surgeons that just like to do surgery, you know, and that pays for things and they're surgeons and that's what they do. So you end up getting that $250,000 multi-level fusion that you referenced earlier and that happens a lot. You know that happens a whole lot and you can pay for a lot of physical therapy visits and you can pay for a lot of things with $250,000 a pop or even $50,000 a pop, you know, on some of these surgeries that maybe aren't as necessary and things like that. So I think we have to be cost savers rather than revenue generators that mindset. And if you can save a lot of dollars, then you maybe get a bigger slice of that dollar pie. Or we have side programs where we're doing counseling and education and being again that health quarterback for patients and that gets paid a dollar amount as well and that becomes another income stream or another revenue source for your business. You know, outside of just the normal rehab, we're always going to be in rehab and that's great, that's awesome. But I think that we need to maybe look at other ways to source revenue and try to figure out if we can get a bigger slice of that pie and realize some of the downstream savings that we might be able to help people with. The problem with that is you got to get a research study to prove that you can save this dollar amount and you've got to be able to model what that dollar amount is over a certain population and come up with a payment structure for that. So this is a big lift. It's not something that's easy, it's not something that we could, you know, snap our fingers and do, but for me it's a direction I see that we should go as a profession to help, you know, correct or mitigate what I see as the number one problem for our country and our healthcare system is how just generally unhealthy we are. That's why universal healthcare would never, ever, ever work in the United States, because we are just too unhealthy when you look at the countries that it does work in, places like Norway and Sweden and that sort of thing in general, those folks are a heck of a lot healthier than the average American, so their system is not just pouring money into the treatment and maintenance of chronic diseases like we are in the United States. We would have to have like a 50% health tax or something like that to to actually provide like really good universal healthcare in the United States, and I don't see very many people raising their hand and saying I would like to give away 50% of my income.

So what you're telling is like dry needling. Level eight or manipulation level 16 isn't going to solve this problem.

You know, I don't maybe it has a role, but I don't think that that's gonna be the big thing that moves the needle.

Yeah, yeah, and I again I joke, but I just think we still have a profession that wants to just do the rehab and find it and fix it approach where we have a huge opportunity. And this is just. But I just we could if we step into the lifestyle wellness space. I have patients regularly who check in, you know, monthly, and probably could do a lot more. I just we just aren't in a situation and we're in a university setting where I'm not as fiscally under as much pressure and things with that. But I think there is so much opportunity for wellness, osteoarthritis, god, keeping people moving, keeping them active. We, we own exercise while rehab. Why don't we own it as people progress and move forward and and try to manage their conditions long-term? Because guess what, that Arthritic joint and change ain't gonna go away, but they're their management strategy. You could be hanging alongside with those some folks who navigate persistent pain issues and get back to valued living things Often needs support. That whole restore back trial recently booster sessions, you know, shown this helps significantly. I mean there's a lot of data out there. I think you do bring up good points. We need to start collecting data to show Downstream. The problem is is we want. We have such a like immediate gratification, like a health care system, like if it doesn't immediately save money it ain't worth it. Um, where, if you, if you put in some studies and some time to where we get people downstream, how, how, if we prevent that, even a few? You know multi-level fusions in a in a year in our practice, or you know, in total, joint replacements and things like that, which we know they get thrown around a lot more liberally Due to some of the financial incentives out there and some of the biases of the practitioners and again we're biased as as physios and things too with our conservative care approach. Just a lot cheaper and a lot less invasive. I was still patient, so but yeah, there's, there's some definite challenges systemically in the in the health care system. I do agree with you. We have a huge opportunity if we're willing to just put down, to find it, fix it, a thought process and let's Be the guide. By the side, the whole Alfred phenomenon You've heard us rail about, you know, time after time on the podcast. I just hope folks will take heed to that. I mean, we got folks. I got my friend Joe Camarado who's doing, you know, teaching physical therapists. How do I get people into a program after they're done with care to start one as a Business, continue to bring in revenue, so, and you're serving a patient with some significant value? It's not like you're. You have some like program that's just fleecing people money. You're. You're saving them money downstream by getting them involved in such a you know, fitness and wellness program. I'm gonna respect your time today, my friend. I really appreciate it. It's been good catching up with you. My blood pressure is raised appropriately, as it always is when we start talking about some of these topics. I'm just curious anything you want to leave folks with before we part ways today.

You know nothing other than you, please feel, feel free to reach out to me at any point in time. I'm an open book now on on Instagram and Facebook, something like at Dr Jared Hall DPT or something like that. You know I I would. I would also like to say I've been in this business and management thing for the last couple of years, which has caused a lot of people to interact with me now to not remember that I'm Also a clinician and I was. I was a, I was an educator and clinician and stuff before I was in business, so that stuff is not lost on me. I've been there. I understand those things as well, so there's no question that's awful in it. So if you, if you want to pick my brain You're anybody, that's always, you know totally okay to do that.

We'll definitely link Jared social profiles and let you reach out to him. He is not on the evil empire now that he's in management, he does still hold clinical experience and still sees patients. So I think sometimes it's interesting to see like, oh well, you're just in management now You're, you're on there, they're team, you're not really. Yeah, I think it's. It's good to have that full perspective and see, I think it's a unique perspective. I mean it did. Just, there's a lot of folks who are so strictly clinical that they don't see the fiscal side and I think you did a great job today bringing some of the the challenges that we see when you look at the business side of what we do in health care. So appreciate your time today, my friend. Hope you and the wife and family have a good rest of your weekend and we hope to get you back on the podcast soon.

Sounds good man.

All right, you all who are listening, we'd love to have you subscribe to the podcast on your podcast provider and if you're on YouTube, we'd love to hear you or see you subscribe on YouTube. Drop a comment in the comments, just so we can kind of hear what your thoughts are on some of the challenges we're facing here financially not maybe just physio. You might be in a different profession or maybe you're a patient who's dealing with some of these financial challenges as well, as you see, insurance companies and other challenges that we spoke about today. So until next time, we'll talk to you all next episode.

This has been another episode of the modern pain podcast with dr Mark Cargilla. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit ModernPainCarecom. Also visit the pain masterminds network on Facebook for free education and resources. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain this is the modern pain podcast.