In healthcare, we spend an enormous amount of time debating strategy at the top and performance at the front line.

Executives talk about margin compression, reimbursement cuts, value-based care, and growth. Clinicians talk about burnout, productivity expectations, documentation, and patient care.

But there’s a critical layer in between that determines whether any of this actually works.

Middle managers.

I’m talking about roles like physical therapy directors. Rehab managers. Nurse managers. Clinical supervisors. Operations leads.

These roles are often treated as administrative overhead but, in reality, they are one of the most important, and most fragile, components of the healthcare system.

If you want financial stability, operational reliability, and sustainable patient care, your middle managers are not optional. They are the operating system.

Middle Managers Are Where Strategy Either Becomes Reality or Dies

Healthcare organizations love strategic plans.

Five year growth projections. Access initiatives. Quality dashboards. New service lines. “Transformational initiatives”. These buzz words really get the McKinsey consultants fired up.

But none of these things happen because they were written in a boardroom or discussed in a meeting.

They happen, or they fail, in the daily decisions made by middle managers:

• How schedules are built

• How staffing shortages are handled

• How policies are interpreted in real time

• How productivity targets are enforced (or ignored)

• How frontline concerns are translated upward

Executives design the intent and frontline staff execute tasks.

But middle managers translate intent into behavior.

When that translation fails, organizations blame the “culture”, “resistance to change”, “staff burnout”, “shortages”.

Often, the real issue is that the middle layer was never equipped to do its job.

Financial Performance Is Won or Lost in the Middle

Let me be blunt… healthcare margins don’t erode at the executive level. They erode operationally.

Middle managers directly influence things like utilization, no-show rates, visit volume, overtime usage, staffing ratios, supply costs, documentation quality (and therefore billing integrity).

A manager or director who understands demand patterns, lead time, capacity constraints, variability (both predictable and unpredictable), and incentive alignment, can protect hundreds of thousands, or even millions of dollars annually.

Conversely, an undertrained manager can quietly bleed revenue while “meeting productivity” on paper.

Finance doesn’t fail loudly in healthcare. It fails through thousands of small, unmanaged operational decisions.

Those decisions live in the middle.

Middle Managers Are the Shock Absorbers of the System

Healthcare systems are under constant stress between reimbursement cuts, regulatory pressure, staffing shortages, patient expectations, tech developments, competing organizational priorities,…etc.

Middle managers absorb that pressure from both directions.

From above…. “more access”, “better metrics”, “we need this rolled out by next quarter”

From below…. “we’re short staffed”, “this workflow doesn’t make sense”, “morale is low”

They are expected to enforce standards, maintain morale, deliver results, stay compliant, be empathetic, be decisive

Often without authority, training, or real support.

When middle managers fail, organizations interpret it as a “people problem”.
But this is not accurate.

Why Healthcare Struggles to Develop Middle Managers

Most middle managers in healthcare were promoted because they were either strong clinicians, reliable employees, or high performers.

Not because they were trained operators.

They’re then expected to suddenly master areas like budgeting, staffing models, conflict resolution, data interpretation, regulatory risk, and cross-departmental influence.

This results often times in reactive leadership, inconsistent enforcement, burnout, quiet disengagement, and holding patterns instead of improvement.

Healthcare doesn’t lack talent. But it does often lack intentional manager development.

The Organizations That Win Invest in the Middle

High-performing healthcare organizations understand something critical:

You scale care by stabilizing the middle.

They invest in operations training (not just compliance), decision-making frameworks, communication skills across levels, data literacy, and accountability systems that support (instead of punish).

They treat middle managers as operators, translators, risk managers, and culture carriers, rather than glorified schedulers or administrative buffers.

And they get predictable results… better access, more stable finances, less chaos, higher staff retention, and fewer “fire drills”.

Final Thought: Middle Managers are the Leverage Point

Healthcare loves to talk about fixing the system.

But systems don’t change at the extremes. They change at the connection points.

Middle managers are where clinical care, operations, finance, and strategy intersect.

Ignore them, and no amount of vision will save you.
Develop them, and even imperfect systems can perform pretty well.

If healthcare wants sustainability, not just survival, it’s time to pay attention to this vital connection in the system. They aren’t the middle of the organization. They are the system.

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Outpatient physical therapy is one of the most essential, and sometimes, misunderstood components of the musculoskeletal care ecosystem. For patients, it feels simple: you show up, work with a therapist, make progress, and (ideally) return to full function. But behind the scenes, outpatient PT is a business model built on labor-intensive care delivery, some regulatory constraints, complex payer dynamics, and fairly thin operating margins.

Here I’ll break down how the outpatient physical therapy model works economically, why the margins are what they are, and where the industry is heading. It will be particularly useful for new graduates, managers who run clinic operations, or those thinking about starting their own clinic.

This article is just a starting point, so I will keep things fairly simple and provide numbers as examples/estimates. If there is more interest in this topic, I’ll be happy to dive deeper in the future.

One more important point…this article is assuming that the business primarily functions as an in-network practice. There are some practices that do not rely on private or public insurance and function on out-of-network or cash-based business models. There are differences in those models, which I won’t get into here.

1. What Outpatient PT Actually Sells

Before we get into the numbers, it’s important to understand the product. What is it exactly that we as therapists get paid for?

At its core, outpatient PT sells- billable units of therapist time. That’s it.

A “unit” is typically a 15-minute increment, and therapists bill for a mix of:

• Evaluation codes (initial visit assessments)

• Therapeutic exercise

• Manual therapy

• Neuromuscular reeducation

• Modalities (heat, e-stim, etc.)

Most therapists bill 3-5 units per visit, depending on state law, plan of care, and patient complexity.

Volume is everything. Because reimbursement per unit is low, the sustainability of a clinic depends on seeing enough patients per day to cover labor, which is the single biggest expense.

2. Where the Money Comes From

Payer Mix Drives Revenue

A clinic’s revenue is a blend of:

• Commercial insurance (typically higher reimbursement)

• Medicare (reliable but usually lower rates)

• Workers’ compensation (can be higher reimbursement, but more paperwork)

• Cash services (growing segment)

• Medicaid (reimbursement often below cost of service)

• Capitated or value-based arrangements (emerging but still very rare)

The exact numbers will vary on setting, company size, geography, and a host of other factors, but here are some general numbers.

Commercial payers typically reimburse $80-$120 per visit. Much more if out-of-network benefits are there.

Medicare reimburses $70–$120 depending on geography and unit mix.

Cash pay ranges from $85–$150 per session (and sometimes much more, often completely margin-positive).

The right payer mix can be the difference between a thriving clinic and a struggling one.

3. Major Cost Drivers

Outpatient PT is a labor-intensive business. An example cost structure looks like this:

A. Clinical Labor (55-65% of costs)

This includes:

• PT salaries

• PTA salaries

• Benefits

• Continuing education requirements

• Hiring and retention costs

Because care is very difficult to automate and is highly regulated, clinics rely on clinicians delivering hands-on or supervised care. Many clinics skirt around some of these costs by using non-licensed labor (this is not legal, nor reimbursable, but that’s a conversation for a different day).

B. Rent and Facilities (10–20%)

A typical clinic may be 2,000–4,000 sq ft, with costs varying by market. While PT does not require the equipment intensity of a gym, it does need enough space for treatment tables, open movement areas, and private rooms.

C. Administrative Overhead (10–15%)

Billing teams, front desk staff, scheduling, prior authorization, compliance all fall here. PT is documentation-heavy and requires significant clerical work.

D. Supplies, Equipment, and Miscellaneous (5–10%)

Therabands, exercise equipment, cleaning, EHR licenses, and more.

Margins are thin. A well-run clinic may achieve 20% EBITDA, while underperforming clinics may struggle to break even.

4. The Throughput Equation

The key operational challenge is achieving efficient throughput without compromising care. This is the crux of the problem in volume-based clinics.

Most clinics rely on:

• 45–60 minute initial evaluations

• 30–60 minute follow-up sessions

• One PT seeing 10-15 patients per day

• Support from PTAs and techs to increase capacity

A clinic typically needs ~25 patient visits per therapist per week just to cover salary-more for profitability (and possibly more depending on salary and payer mix).

5. Multi-Clinic Organizations: How Scale Changes the Model

Large PT groups operate 20, 50, or even 100+ clinics. Scale brings advantages.

You get centralized billing and revenue cycle, negotiating leverage with payers (especially if you are dominant in a particular region), and shared of marketing/recruiting/training costs.

But scale also introduces challenges like maintaining culture, ensuring quality across locations, keeping clinician burnout low, managing increasingly complex HR and compliance requirements.

Bigger isn’t always better, but it is the way of things in healthcare.

6. Trends Shaping the Future of the Outpatient PT Model

A. Consolidation

Physical therapy as an industry is largely fragmented (meaning it is dominated by small, independent clinics rather than a few large national chains). Private equity and larger strategic buyers have been actively acquiring outpatient PT practices and building larger platforms.

B. Shift Toward Value-Based Care

Payers are experimenting with episodic payments or outcome-based bonuses, particularly those that involve multiple providers (not just PT). While promising, these arrangements require a lot of data infrastructure, consistent clinical pathways, and arrangements which are quite rare in the PT-world.

C. Hybrid Virtual/In-Person Models

Technology is allowing for remote exercise supervision, symptom tracking, and adherence. Clinics that combine hands-on care with digital follow-up may reduce no-shows, extend care plans, and improve outcomes if done correctly. Telehealth has also expanded significantly since COVID and with the rise of artificial intelligence, Digital MSK has become a competitor for the standard brick-and-mortar PT clinic.

D. Increased Demand Driven by Aging Population

By 2030, we’re going to have a lot more Americans over the age of 65. This will undoubtedly create more demand for non-pharmacologic, non-surgical interventions for chronic MSK conditions.

E. Labor Pressures

Besides the increasing demand, there is a national shortage of PTs created by the educational bottlenecks in training PTs, worsening reimbursement rates, massive student debt, and increased burnout and turnover of therapists leaving clinical care. There are entire forums, groups, and courses now dedicated to non-clinical roles for “recovering clinicians”, some of which contain the most talented clinicians leaving the profession entirely to pursue other fields.

E. Employer Partnerships

Direct-to-employer MSK management and early PT access reduce downstream medical costs, creating new business opportunities. However, these markets have become very saturated in the last few years and difficult to break into.

7. Why the Model Works…Despite Thin Margins

Despite all the above, Outpatient PT still works because on a fundamental level it still largely delivers high patient satisfaction, good clinical outcomes, some cost savings, and recurring, predictable visit volume for business owners, PE firms, and strategics.

It’s not a high-margin business…but it is a high-value one, both clinically and economically.

For health systems, insurers, and employers, PT still remains one of the best investments in musculoskeletal care.

For patients, it’s a pathway back to movement and independence.

And for clinicians, it’s meaningful, relationship-based work supported by an increasingly sophisticated operational engine.

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The rehabilitation world lit up this month with headlines about the Department of Education’s decision to classify physical therapy programs as “non-professional degrees” for federal loan purposes.

Predictably, the announcement triggered outrage across allied health.

But here’s the truth nobody is saying out loud:

This change may be one of the best things that has happened to the PT profession in the last 20 years.

Not because PT isn’t a true “profession” …. it absolutely is.

Not because the work doesn’t matter… it matters more than ever.

But because this regulatory shock is finally forcing a reckoning with a broken economic model that has quietly been hurting students, clinicians, and the profession for well over a decade.

In short: this is the disruption we needed.

Let’s break down why.

This Ends the Tuition Arms Race That Has Been Bleeding Students Dry For years

DPT programs have existed in a world without pricing brakes.

Unlimited Grad PLUS loans = Unlimited tuition inflation.

The result?

• $150K–$220K price tags

• 2:1 or even 3:1 debt-to-income ratios

• New grads living like indentured servants

• A generation of PTs postponing homes, families, and financial stability

The new loan caps immediately apply pressure to universities to justify their cost. For the first time in decades, schools will need to:

• Compete on price

• Compete on professional outcomes

• Eliminate bloated administrative costs

• Innovate program design

• Potentially reduce tuition or apply scholarships to offset the cost
  

This is healthy.

This is overdue.

This is how you reset a market that stopped regulating itself.

This Will Redirect Students Toward Higher-ROI Career Decisions

Nobody likes to admit this, but the federal government just did something profoundly student-friendly:

It forced an honest conversation about ROI.

For too long, students, who are often young or may be coming from modest backgrounds, were encouraged to take on $180K of debt for a job that reliably pays $80K-$95K.

That arithmetic has never worked.

By limiting borrowing, the rule protects future students from making financially catastrophic choices. It pushes them to:

• Seek lower-cost DPT programs

• Demand transparency

• Explore MSK careers with higher earning potential

• Avoid debt traps that take decades to escape

This is a feature, not a bug.

Better-informed students means better-aligned career choices means a more sustainable, financially stable workforce.

The Market Correction Will Strengthen the Profession Long-Term

While some view this as “de-professionalizing,” it’s actually the opposite.

Professions grow stronger when:

• They enforce quality

• They eliminate predatory educational models

• They maintain high standards

• They ensure financial sustainability for graduates

This change ignites all four.

In the long run:

• Weak programs will close

• Strong programs will get stronger

• Tuition will normalize

• Workforce retention will improve

• PT will regain prestige grounded in value, not debt load

The profession becomes leaner, smarter, and more durable.

This Will Accelerate Innovation in PT Education and Care Delivery

Constraints create creativity.

Expect to see more hybrid DPT learning models, competency-based curriculums, shorter and more efficient programs, employer-funded tuition pipelines, and tech-enabled clinical education

A more innovative, agile profession is good for everyone… patients, employers, clinicians.

This Forces Health Systems to Finally Address Retention, Not Replaceability

The old model assumed: If a PT leaves, we’ll just hire a new grad.

That assumption is gone.

Now health systems must invest in career ladders, leadership development, mentorship, improved workload and staffing models, PTA/tech integration, clinician well-being initiatives,...etc

These changes were needed anyway. The new rule accelerates them.

The Big Picture: This Is a Reset, Not a Recession

The loan rule change is not an attack on PT. It’s a correction.

A painful correction? Yes, in the short-term

A needed correction? Absolutely

A catalyst for a stronger future? Without question

The DPT degree will survive.

The PT profession will thrive.

But it will evolve… with more discipline, more strategy, and more innovation.

And that’s why, in the long view, this is a great thing for physical therapy.

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Have you ever stood in a long line at a restaurant to pick up food or get a table, feeling your frustration rise by the minute? Recently, I found myself in that exact situation at a bustling Italian eatery. The place was packed to the brim, and a line of hungry patrons stretched to the door just to pick up takeout. People were visibly upset and impatient—understandably so, as their stomachs were growling and the wait was longer than expected.

But then, the restaurant staff did something brilliant: they started offering slices of fresh pizza to everyone waiting in line. Suddenly, the grumbling crowd turned into a line of smiling, appreciative customers. Despite the wait still being as long, having that small gesture turned frustration into gratitude, and the atmosphere became more positive almost instantly.

This experience left me thinking: What can physical therapy clinics and other outpatient medical offices learn from this scenario? While you probably won’t be handing out free pizza to your patients (or maybe?), you can adopt the restaurant’s strategy of proactive kindness, empathy, and positive engagement with your staff.

1. Acknowledge the Wait

Sometimes, patients will have to wait—maybe an earlier appointment ran over time, or a new patient needed extra attention. Rather than ignoring it and leaving patients to stew in frustration, have your staff acknowledge the wait. A simple: “I’m sorry for the delay. I’ll be with you shortly,” goes a long way toward helping someone feel seen and valued. In a physical therapy setting where patients may already be in pain or discomfort, recognizing their time and inconvenience is crucial. It doesn’t so much matter what the reason is, so long as they are acknowledged with some reason.

2. Offer Immediate, Tangible Comfort

The Italian restaurant gave out free pizza to ease hunger and tension. While it may not be feasible (or healthy!) to hand out pizza in the waiting room, consider small “comfort” offerings that would make waiting easier. This could be providing fresh lemon water, coffee, a healthy snack (if appropriate), or even something as simple as comfortable seating, quality reading materials, or short educational videos that may be helpful from a therapeutic standpoint. Sometimes, a warm greeting and a personal check-in—“How are you feeling today?”—can also serve as that extra “slice” of kindness.

3. Communicate Clearly and Manage Expectations

The restaurant staff successfully calmed tempers by showing they understood customers’ frustrations. In outpatient practices, managing expectations and communicating timelines can transform patient experience. If there’s going to be a delay, let them know approximately how long it will be and why it’s happening. Share updates: “We’re running about 10 minutes behind schedule.” People are far more patient when they feel informed and included. It sounds obvious, but not always implemented with consistency, and rarely part of staff training.

4. Personal Touch Points

The restaurant’s free pizza wasn’t just about filling empty stomachs; it was an act of empathy that said, “We see you, and we appreciate your time.” In physical therapy or any medical practice, you can craft personal touch points that create the same feeling. Perhaps the front-desk or ancillary staff can spend an extra minute checking on patients’ comfort—how are they feeling that day? How has their condition improved or changed since the last visit? These small gestures help patients feel appreciated, not just a time slot on a schedule.

5. Transform Frustration into Appreciation

Ultimately, the Italian restaurant turned an awkward, tense moment into something special by going above and beyond. In an outpatient physical therapy practice, consider small but meaningful ways to surprise and delight patients. Maybe it’s a follow-up call after a tough session to see how they’re feeling, or a quick congratulatory note when they hit a milestone in their recovery. These genuine, “above-and-beyond” moments can leave a lasting positive impression, just like a slice of hot pizza did for the restaurant’s patrons. The pain point is the opportunity to build the relationship and improve retention and compliance.

Running an outpatient physical therapy practice can feel like a juggling act of scheduling, paperwork, and clinical care. But no matter how busy you are, always remember the power of empathy and thoughtful service. Just as that bustling Italian restaurant turned hungry, frustrated customers into happy, loyal fans, you can transform a stressful wait into an opportunity to show patients that you value them.

By acknowledging their wait, offering comfort, communicating clearly, and adding a personal touch, you’ll cultivate a therapy experience that patients appreciate—and keep coming back for. If you’re a clinic owner or operator, this is something to consider. We all say we want this level of customer service, but how many operators will invest the time, energy, effort, training, and financial resources needed to coach their teams to behave in this manner?

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The MSK community largely faults the health insurance industry for many of the problems in today’s healthcare environment, but as the saying goes— people who live in a glass house shouldn’t throw stones. If we look inward to our own profession, especially when it comes to outpatient orthopedics and private practice, we will find a catalog of insurance machinations and manipulations that at best fall into the “grey area” of private practice, and at worst, considered fraudulent.

What I have listed below are some questionable or potentially unethical practices sometimes seen in the outpatient physical therapy world—particularly around in-network vs. out-of-network billing—and how they can negatively affect patients and therapists.

Of course, many PT clinics operate ethically and do not engage in such practices, but these examples illustrate red flags that patients and clinicians should be aware of. In general, the examples below are applicable to both PT clinics as well as other types of healthcare practitioners such as physicians and chiropractors.

If you are a patient, you will find the points below highly valuable to avoid a surprise bill and being taken advantage of financially for your outpatient physical therapy visits.

If you are a clinician, you will find the information below helpful in avoiding clinics that abuse your license and put you in legal jeopardy.

If you are a practice owner, manager, or executive- the information below can be used to ensure that your practice is compliant for regulatory purposes.

Before we get to the meat-and-potatoes, for those who aren’t familiar with in-network vs out-of-network, let’s briefly define what we’re talking about.

The terms in-network and out-of-network refer to a clinician’s contractual relationship with a patient's health insurance plan, and this significantly influences the cost of services for the patient and the insurance plan.

Clinicians who are in-network have formal agreements with specific health insurance plans to offer services at pre-negotiated rates. These rates are typically lower for the insurance company and therefore, they incentivize the patient to go this route by making the out-of-pocket expense (e.g. co-pay/co-insurance) cheaper for the patient. For the clinician, opting for in-network status with insurance companies can lead to more steady patient referrals. Essentially, clinicians are agreeing to lower their rate in exchange for a greater volume of patients.

In contrast, clinicians who are out-of-network do not have contracts with a patients’ health insurance plan, allowing them to set their own rates. These rates are based on what insurers would refer to as “usual, customary, and reasonable” charges for similar health professionals in a given geographical area. Regardless of how they are defined, out-of-network rates typically involve much higher payment from both the insurance plan and the patient. Insurance plans will often charge patients higher out-of-pocket costs (co-pays/co-insurance) to steer them away from seeing these clinicians and toward their in-network counterparts.

This is all fairly straightforward, but the complexity arises when you consider that some patients’ health insurance plans contain BOTH in-network and out-of-network benefits (meaning the patient can see both types of clinicians) and some contain ONLY in-network benefits (meaning the insurance will not cover out-of-network providers whatsoever). And the matter is further complicated when some clinicians in the same practice have in-network, while others have out-of-network status.

A common misconception is that an out-of-network clinician will be better- more safe or effective- than an in-network clinician. This isn’t necessarily true as network status has very little to do with treatment efficacy or clinician skill in a fee-for-service environment.

Okay, so with all of that on the table, without further ado, let’s get to the in-network/out-of-network schemes…

1. Misrepresenting Network Status
This typically occurs when a patient calls to make an initial appointment and asks the clinic if they “take my insurance”. The clinic tells patients that they do take their insurance in order to encourage them to schedule an appointment. In reality, they may not disclose whether they are in-network or out-of-network with the patient’s specific plan. If they are out-of-network, the patient might be billed unexpectedly high out-of-network fees, leading to large bills after the fact. The way to resolve this problem is for the patient to specifically ask the practice “do you participate with my plan” or “are you in-network with my plan” instead of “do you take my insurance?”

Why it’s done:

• Out-of-network reimbursement rates are often higher than in-network rates. The clinic may collect higher payments from the insurance company (if the plan has out-of-network benefits) or from the patient (who may be subject to a higher deductible and co-insurance for out-of-network care).

2. Dual Contract Games

Following the previous deception, here is another insidious one you should be aware of. Dual contract schemes occur when a practice is contracted with an insurance carrier (in-network) for certain clinics or under certain clinicians’ IDs but also operates an out-of-network “side entity”. They might selectively route patients or claims through whichever entity reimburses more.

Why it’s done:

• To maximize revenue the practice cherry-picks which patients or claims to bill as out-of-network (often those with good out-of-network benefits) and avoids the lower reimbursements from in-network rates. For patients, this leads to confusion about coverage and unexpected bills. They may be steered into more expensive out-of-network services without fully understanding their financial responsibility and that the practice could have billed them in-network resulting in a much lower bill.

3. The Network “Bait and Switch” Scheme
This is an off-shoot of the “dual contract games” scheme and this one can really hurt the clinician as well as the patient. A “bait and switch” occurs when a clinic (as a business entity) has an in-network contract with a particular insurance company, but one or more of the physical therapists (or other clinicians) working there do not individually participate in that same insurance network. In other words, the clinic and certain therapists may be credentialed as in-network, while another therapist on staff remains out-of-network—even though they all practice under the same roof.

You’ve probably heard stories about how a patient may go to a hospital for a procedure and the facility and services are covered but somehow the anesthesia isn’t covered by the insurance because the anesthesiologist is out-of-network. This is a similar issue and you might be wondering how this sort of thing can even happen. Read on…

Outpatient PT clinics often have a “group” contract with an insurance carrier, tied to the clinic’s tax ID. Each individual clinician may also need to be credentialed with that insurer in order to be considered in-network personally. In some cases, a clinic might hold a group contract, but a specific therapist either never completed or failed the credentialing process—or the therapist or clinic specifically chooses to keep that clinician out-of-network for financial reasons.

At this point, a few things can happen when it's time to bill the insurance for the visit:

1. The in-network clinic bills under the group’s contract and the insurance claim typically goes out under the clinic’s tax ID. The therapist performing the service is also identified on the claim (via their NPI). If the therapist is not credentialed, an insurer may reject or reduce payment for that therapist’s services—or flag it as out-of-network—resulting in higher patient costs.

Or

2. The clinic might attempt to “hide” the fact that the therapist is out-of-network by billing under another therapist’s NPI or otherwise misrepresenting the rendering clinician (which can be considered fraudulent).

Or

3. The clinic will purposefully bill under the out-of-network clinician even though the clinic itself is in-network. The insurance company will pay for the claim and make the check payable to either the patient or the rendering clinician. The insurance company files 1099 forms with the IRS under the clinician’s tax ID, showing those out-of-network payments as the clinician’s income.

If the clinician is unaware or never receives proper statements, they do not report this additional income on their taxes. When the IRS compares the clinician’s tax return (W-2 wages, or other reported income) with the 1099s it has on file from the insurance company, it sees a discrepancy. Resultant, the clinician could face penalties or audits due to “underreporting” income—even though they never actually received or kept that money.

Why it’s done:

• Again- to maximize revenue. The practice cherry-picks which patients or claims to bill as out-of-network. This subjects the patient to potential higher out-of-pocket costs and opens up the practice and the therapist to potential insurance fraud, tax evasion, and other legal exposure. The worst thing about all of this is that the therapists and other clinicians are not well-educated on the business aspect of clinical care and may often not even realize what is happening under unscrupulous management practices. If patients discover they were unknowingly receiving care from an out-of-network therapist in an “in-network” clinic, they may blame the therapist or the clinic for surprise bills. This can harm the therapist’s professional reputation and patient rapport. Finally, if patients can’t afford the unexpectedly higher out-of-network costs, they may have to discontinue or seek care elsewhere—disrupting continuity of care.

4. Inappropriate “Balance Billing”
When a clinic is out-of-network, they often receive a lower portion of their charges from insurance. Some unscrupulous practices will then bill the patient the difference between the clinic’s full “cash rate” and what the insurance company paid, despite contractual or state law prohibitions on certain balance-billing practices.

Why it’s done:

• The clinic aims to collect more money by passing on the insurer’s discounted or partial payment shortfall to the patient. This results in the patient receiving unexpected, often large bills that were not initially explained, creating financial burden or leading patients to avoid future physical therapy care.

5. Waiving Copays to Induce More Visits
A clinic might tell patients, “Don’t worry about your copay,” to entice them to come more frequently. However, most insurance contracts prohibit routine waiving of copays and deductibles.

Why it’s done:

• By removing any out-of-pocket costs, the clinic makes it more appealing for patients to return, which can lead to more billable services. In some instances, the clinic may falsely inflate charges or number of visits to offset waived copays. If discovered by the insurer or regulators, patients may face retroactive billing for copays or run into coverage issues in the future. In extreme cases, the insurance plan might refuse to pay claims or could even drop coverage.

6. Upcoding Services
A clinic might use a higher-paying code for a procedure that was actually something simpler (referred to as “upcoding”). For example, if billing for neuromuscular re-education results in higher reimbursement than therapeutic exercise, the clinic may bill for the former even when the latter was the service actually rendered. Sometimes this can get tricky because there is service overlap, so how these services are documented often determines its defensibility.

Why it’s done:

• Increases the total billable amount per visit, especially out-of-network (where there is generally less oversight and fewer contract rules). This could lead to higher out-of-pocket costs (copays, co-insurance, deductibles). This may also flag the patient in their insurer’s system if there are irregular billing patterns, such as regularly billing for physical therapy re-evaluation when only a progress note was completed. Insurers sometimes suspect fraud and may delay or deny legitimate claims. They may also retroactively request payment from the clinician or practice.

7. Over-utilization of Services

This is the most common scheme, used in most healthcare facilities. The reason being is that it is largely a grey area. Depending on documentation, additional services can be justified from a legal perspective. Overutilization manifests in the form of scheduling more PT visits than are clinically necessary, or adding unnecessary treatments or modalities each session to justify higher billing.

Why it’s done:

• Each additional visit or service can bring in more revenue, especially if billed at out-of-network rates. For patients, this results in increased cost sharing (co-insurance) for visits and treatments that may not be necessary, as well as wasted time and possible discouragement from continuing necessary care in the future due to financial burdens.

So there you have it: the dark side of clinical practice. Some outpatient physical therapy clinics and other private practices exploit in-network vs. out-of-network differences by misrepresenting their network status, overbilling services, engaging in excessive or unnecessary treatments, or improperly balance-billing patients. These tactics can saddle patients with unexpectedly high costs and undermine trust in the healthcare system. They also hurt therapists who put their license at risk, and may face legal and financial repercussions by other entities such as the IRS. By being informed, patients and good clinicians out there can protect themselves from these unethical practices.

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The outpatient physical therapy business model is broken. More specifically, the third-party Fee-for-Service (FFS) in-network reimbursement model, once a source of business growth for physical therapists, is now slowly constraining the profitability of smaller practices that do not have negotiating leverage over payors nor economies of scale to weather increasing overhead costs.

There was a time when there were higher reimbursement rates combined with looser restrictions (a lower burden of pre-authorizations, visit limits, medical necessity audits, billing/coding requirements, payment delays..etc), but those “good old days” are gone.

On a fundamental level, FFS is not a significantly profitable business model for physical therapy in today’s world. And this is because the FFS model does not properly capture the value creation achieved from physical therapy, such as mobility and quality of life improvements, prevention of unnecessary procedural care, and chronic disease management. Therapists can not extract the value achieved from these activities in terms of revenue in this business model. There is no CPT code for “prevented knee arthroscopy” or “abolished low back pain without the need for an expensive MRI or CT scan”.

So is the profession destined for an agonizing decline? What can be done to counteract this trend?

The bright side of the story is that physical therapy as a service has strong demand in the healthcare market. The value is still recognized. We just need to modify how we extract value. And the best way to do this is to look at other business models, in healthcare and elsewhere, that have successfully captured value with analogous market dynamics and constraints.

Hospital Systems, Loss Leaders, and The Airline Industry Offer One Solution

Perhaps the closest analog is our friends over at the hospital systems. Hospital systems have services such as primary care and emergency care at scale. The only issue is that primary care is largely a loss leader for US hospitals. Many hospitals lose money on primary care visits. However, these visits do act as a referral source for higher-margin services such as orthopedic and cardiac surgeries. Similarly, physical therapy, with ever decreasing reimbursement, can act as a “loss leader” of sorts to more profitable, higher margin cash-based services such as medical equipment sales, massage therapy, fitness classes, personal training, and coaching/wellness programs.

Providing the service of physical therapy and getting paid for that service may NOT be the correct economic model for this business. On face value, this may seem counterproductive to move away from the core competency of the profession but there is precedence for this type of business model.

In fact, this is actually quite common in many other industries. For example, the airline industry makes some of its revenue on passenger ticket sales. However, in recent years, the ancillary services and revenue streams have contributed substantially more to their overall income. These ancillary services include in-flight services (beverage, entertainment, wifi), baggage fees, and most importantly- loyalty programs. By loyalty programs, I am referring to frequent flyer programs.

Let me state this clearly- Airlines don’t make that much money by charging you for a seat on their plane (their core competency). They make their money by partnering with credit card companies for points and sales of miles. Credit card companies will give the airline profits from its high-margin/high-interest rate debt that they are issuing to credit card holders who entice you to build that high interest debt with airline points.

These companies also enhance their revenues by co-branding credit cards, so airlines earn revenue every time a transaction is made, when someone opens a new credit card, or when an annual fee is paid on that card. All of these strategies (and more) have transformed these frequent flyer programs into financial assets with significant standalone value that sometimes even exceeds the airline’s core operations!

But airlines aren’t the only ones using this strategy. Ancillary revenue streams have become significant contributors to overall profitability in other industries such as hospitality (think major hotel chains that make lots of profit not through sales of rooms, but through services like in-room dining, WiFi, event hosting, and ofcourse- alcohol sales).

Value-based Care Offers Another Great Solution

The other solution to the FFS problem lies in improving the overall care quality and entering into different types of contracts other than FFS. By moving from a no-risk / fee-for-service model to a model that assumes some level of risk and charges self-insured employers a bundled payment or case rate for physical therapy services, some companies such as Integrated Musculoskeletal Care (IMC) have been able to grow and expand by contracting directly with employers (rather than insurance companies) and contractually guaranteeing both clinical and financial outcomes.

In fact, a study published in 2019 demonstrated how IMC uses standardized, quality-assured treatment for low back pain to achieve a cost-savings of 51% in musculoskeletal care compared to standard community care through quantifiable reductions as demonstrated in claims data for downstream interventions such as MRI, spinal injections, and lumbar surgeries for a major employer. The savings were consistent after adjusting for age, gender, and other risk factors.

The key to this is increasing the risk on the part of the provider. If patients get better quicker, we get paid more per unit of treatment time. If patients don’t get better or end up using more downstream services, we take the financial loss. And in order to pull something like this off, we need providers trained to a high standard, quality assurance programs built around those standards, and the technology available to measure this data over time.

Why Subscriptions Are Key

Similarly, we can achieve similar results through full capitation or even subscription-based arrangements. If done correctly, we wouldn’t bill FFS, but we would have a constant stream of revenue to manage the MSK health outcomes for a particular population. In this scenario, the patient or the employer is paying a subscription model for a clinic or service.

Subscription services have recurring revenue. And this inherently makes them a more scalable business model in any industry, not just healthcare. In fact, healthcare is not the only industry that uses a FFS business model. Other service-based industries such as legal services, accounting, consulting, automotive repair, plumbing companies,...etc also use a FFS business model. And they face similar difficulties in scaling using the FFS model, namely the fact that FFS:

1. Relies heavily on labor intensity (often skilled labor) making it challenging to scale operations without a proportional increase in workforce

2. Has standardization difficulties as we’ve seen in physical therapy (but also in other professions such as law) where services are tailored to individual clients, complicating efforts to standardize offerings for mass delivery.

3. Has geographical limitations which often require a local presence which limits the ability to expand without establishing multiple physical locations.


Here’s The Point…
The value extraction in physical therapy is based on value that is created by restoring mobility/function, improving quality of life, and preventing unnecessary downstream procedural care. And this is not captured properly through FFS. It is better captured either in a:

1. Recurring revenue stream: such as a subscription service or a value-based care model (such as a bundled payment or case rate) where you’re taking on premium risk.
Or
2. Loss leader model: such as that which is used by hospitals and airlines, where the physical therapy service itself is merely an enticement to higher margin in-demand services like fitness classes, wellness programs, and other modalities.

Which of the two is better? I would say the #2 is the better short-term solution, while #1 is better for the long-term. However, what I can say for certain is that both models can work, whereas FFS is becoming more and more unsustainable in today’s environment of increasing overhead and decreasing third-party reimbursement.

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In the realm of musculoskeletal care, particularly within physical therapy, the importance of technical skills and clinical knowledge is well understood. However, the role of effective communication often remains underappreciated from the standpoint of operational success, even when recognized for its importance in the patient-clinician relationship. 

Communication isn’t just important for clinicians interacting with patients. It is a vital skill that significantly impacts business, management, and operations in physical therapy, leading to improved outcomes, enhanced team dynamics, and streamlined operational efficiency.

If someone asked me what is the number 1 skill of a great manager in the MSK space, my answer would not be clinical skills, data analysis, or fiscal operations. By far the most important skill for operational success is communication…both in the written and verbal form. Therefore, this post will focus on communication from the standpoint of managing staff.

Not As Simple As It Appears

In the business world, we know how changing the words and the headline of an advertisement can double, triple, or even “10x” the response that you get. And I’ve personally witnessed how changing an advertisement to hire a physical therapist can get many, many more times the responses. As managers and leaders, it is our job to coach, coordinate, counsel, evaluate, and supervise through the process of communication. 

Communication seems simple enough as we're naturally wired to do it but my experience has been that while it appears simple on the surface, it is actually very challenging to accurately get a message from one human to another with a high degree of fidelity and consistency. And when communication isn't achieved- misunderstanding, misalignment, confusion, friction, inefficiency, and conflict are the result. 

The Importance Of Communication

Clear communication isn’t typically taught in physical therapy or other clinical schools and professions, but it is universally recognized for its role in engagement and adherence.

Simply put, effective communication helps build rapport between management and staff. When staff feel heard and understood, they are more likely to trust management and adhere to organizational goals and strategic objectives.

Clear explanations about organizational policies, operations, and expected outcomes gives staff the knowledge and motivation to actively participate in the success process, improving adherence to policies and initiatives.

Open-ended questions and active listening enables managers to engage staff effectively. It also helps identify barriers, misconceptions, or other challenges. Addressing these issues early can enhance organizational effectiveness.

Clear communication enhances interdisciplinary collaboration, allowing clinicians to effectively coordinate care with other healthcare professionals. It ensures that all team members are on the same page, sharing insights and expertise, which can lead to innovative solutions, improved patient care, and positive cash flow for the clinic.

So with all the positive benefits of effective communication, how can managers and clinicians do it better?

Principle #1: Assume Responsibility Of The Communication

Let’s first start with the definition of communication. For our purposes, we will define it as something that happens when we transmit messages to another person using words, voice tone, gestures, and other means to share knowledge, feelings or methods in order to achieve an outcome, build a relationship, or spread an idea. 

So the communication begins when you send the message, but where most managers screw up is that they assume it ends when the other person receives the message. In reality, the communication does not end when the other person receives the message, but when the receiver provides you feedback indicating that they understand the message, its level of importance, and what must be done with it. 

Thus, the meaning of a communication is the response that you get, not the message that you send.

So the implication here is that communication is an exchange, not just a delivery of thought processes by a sender. All parties must participate actively in order to complete the information exchange.

And one important principle for effective communication is that the responsibility of communication belongs to the communicator. Every manager should take responsibility for communication, making sure that the communication lands and that it is understood. 

In other words, if someone on the team “doesn’t get it”, the mindset is that the manager is the one responsible for communicating the message in a different way, perhaps “on a different channel” so that the message is received and understood by the staff member. It is not the staff member’s responsibility to “figure it out”. Taking ownership over the communication forces the manager to alter their communication until it lands. 

Principle #2: Four Channels

Human beings process information and communicate in one of four different channels. These channels are visual, auditory, kinesthetic, and conceptual. Visual processors are (you guessed it) visually-oriented. They'll often say things like, “I see what you're saying” or “let me show you something" 

Auditory processors are tuned to the words and the sounds that are coming in and they'll often say things like “I hear you” or “that rings a bell”. They can listen to and learn from audiobooks or from conversations very well. 

Kinesthetic communicators, refers to kinesthesia or body awareness. These are experiential learners. They learn by doing things. 

And conceptual types operate in the abstract space. These people really need to understand the “why” and the logic behind why something works in order to implement it.

Managers need to listen closely to understand their staff so they can start communicating with them on their “channel”. For example, a visual learner may need to see someone doing something so they can repeat it. A kinesthetic type may need the manager to be there while they are actually performing the task to confirm they are doing it correctly. 

Generally speaking, the more channels you can communicate on, the richer the communication will be, and the greater the chance that it will “land”. 

Principle #3: Clarity Is Key

Before you can send the message, and before the message can be received, it must exist in the first place. And most messages are general, nonspecific, unconscious, uninteresting, and they never make an impact either on ourselves or on others. 

It is very important to define any terms, ideas, concepts, or components. The more you refine and clarify your definitions, the better your ability to create messages that are more effectively sent and received, and the better you become at understanding, communicating, and getting results.

Our definitions in our minds are squishy, ambiguous, and undefined enough that we can go through our entire work day without really having to be awake and take conscious and intentional control. The more you define your terms, ask yourself what you mean, and test it against reality, the more it challenges you to become conscious of what you're saying.

So it's important to first get clear about what you're communicating and then use the best means to actually communicate it. And clarifying is key. If you don't understand the essence of what you're trying to communicate, it's going to be difficult to communicate it. 

So when you're starting with an idea, thought, or message that you'd like to communicate, it's important to stop and boil it down to the most basic idea (the key part of your idea or thought) and then to communicate it. It's important that you challenge yourself to be more and more specific and to really define what you want. 

Instead of saying something general like, "I want my staff to answer the phone in a professional and empathetic manner”, you say “I want them to answer the phone by saying ‘Good morning, XYZ Physical Therapy, this is Paul speaking, How may I help you?’

Specificity, concreteness, having a definite descriptive clear language around what you want, what you want to create, and what you want to communicate, is key. 

Principle #4: The Need To Be Right 

When interacting with another person, it's important to remember that we human beings have a really important need to be “right”. We have a high need and a drive to see ourselves as being good and having positive intentions. So when interacting with another person, it's important to make sure and acknowledge their goodness and their positive intentions. This operates as a connection and commonality, but it also allows the other person to let their guard down and realize that this is someone who “gets them”.
 

Now we screw this up oftentimes, largely because we're not aware that people need to be right and they need to be seen as having positive intentions. We often forget that there is a human there, and instead we focus on the ideas or the message on its own. 

The idea of “right” and “wrong” or “good” and “bad” are value judgments. They're just decisions that we make about whether or not we think the other person is correct or incorrect. And we do this in all kinds of ways. We have very subtle ways of approving or disapproving of other people, of hinting that they're wrong, bad, or that their intentions aren't good. And what you will find is if you take all the preconceived notions off and you start interviewing people with an open mind,  everyone thinks that they're right and that they have positive intentions.  

So if you want to communicate well with others- find commonality and eliminate the stance of “you’re wrong”, “you’re bad” or “you don't have good intentions”. 

And to do this, you have to let go of your own need to be right and your own need to be seen as having good intentions because these operate as blocks. And when you let go of this, you don't grasp onto ideas and positions as much. You become more flexible. Metaphorically speaking, you become the water and not the rock, and you can “flow more easily”. You can alter your communication and your behavior better. And you also get rid of what is called sub-communication or subliminal communication of disapproval, which really closes people off. 

So when you're interacting with another person, you want to communicate with them, treat them like they're a good person, and like they have good intentions. And if they say something to demonstrate that they're incorrect or that they don't have good intentions, instead of making them wrong and bad, help them see how a different intention or a different perspective would serve them better (and do it without judgment). Because as soon as you start bringing the judgment in, that's when other people close up. 

Remember people need to be right….or at least feel that they are right. It's important when someone expresses a belief in these moments to treat that belief tenderly and to not attack them or make them wrong for it. 

You can bend someone's belief a little bit, but you can't break it. So don't argue with beliefs because all it's going to do is break the relationship. A much better route is to get into their model of reality, into their world, ask them more, seek to understand until you get it, and then help them take steps so that they can transcend to a different idea or concept. 

If the other person says or does something that doesn’t match your model of the world or your values system, instead of arguing with them, validate their position. This is known as a “steelman” and it is important especially when there's tension or conflict. This relaxes the other person, it brings their guard down, and this is especially true if someone is criticizing you.

Principle #5: Signing Off  On The Message

When communicating with a staff member, if you're sending a message, it's important to get “sign-off” and ask them what they understood. In other words- to get their feedback. 

So once you send your message, ask them for some feedback. And then once they provide you with feedback, clarify it until their sign-off is satisfactory. And you'll notice that most of the time you'll have to go back for two or three rounds of clarification before you will be satisfied that the sign-off really works. 

This is especially important to do when you’re giving your staff specific instructions that you need them to implement. In fact, I used to do this all the time with patients if I gave them any home instructions. I’d tell them everything they needed to know, and then I’d finish off by saying something like “Ok Ms. Smith, I’ll see you next week, but before you go, tell me what you’re going to do at home?”. Compliance is substantially increased when someone can verbalize to you exactly what you want them to do and why you want them to do it.

To conclude, effective communication is the cornerstone of operational success in musculoskeletal care and physical therapy. By assuming responsibility for clear communication, understanding and utilizing different channels, prioritizing clarity, acknowledging the inherent need to be right, and ensuring message sign-off, managers can foster a more cohesive, efficient, and motivated team. This not only improves internal dynamics but also enhances patient care and clinic operations. 

In essence, mastering the art of communication equips leaders with the tools to navigate and resolve challenges, align their teams towards common goals, and ultimately drive the success of their practice. As we continue to emphasize and refine these communication principles, we pave the way for a more effective and harmonious work environment, leading to better outcomes for both staff and patients.

A Happy 4th of July weekend to all my readers and fellow clinicians and managers. With the Holidays upon us, I wanted to kick it off with an interesting topic: 

Is treating patients with individualized one-on-one therapy, seeing one patient every 45-60 minutes, superior to treating 2-4 patients per hour as many in-network clinics do? 

As MSK clinicians, finding the optimal amount of time to spend with each patient is crucial for achieving the best clinical outcomes as well as a great patient experience.

Within the physical therapy profession, there is a debate over whether therapists should see one patient at a time or manage multiple patients simultaneously. Each approach has its own challenges and advantages, impacting the quality of care, therapist workload, patient satisfaction, and insurance reimbursement. Understanding the nuances of both methods can help therapists, clinic managers, and patients make informed decisions about the best treatment model.

One-on-One

Seeing one patient at a time has several obvious advantages. Many patients enjoy and report greater satisfaction from having the full attention of their therapist. They perceive that they get more thorough assessments, detailed education, and greater individualized treatment plans. 

The extra time spent with the therapist often means improved communication facilitating a stronger level of trust and relationship between the two. It also means that therapists can monitor the patient closely and make adjustments to both exercise selection and technique based on the patient’s symptoms. 

But it’s not all sunshine and roses. Oftentimes these clinics are very heavily manual-based, which could place a large physical burden on the therapist. Doing 20-30 minutes of manual therapy on every patient may not be necessary or even clinically indicated.

Seeing only one patient at a time obviously limits the number of patients a therapist can see in a given day, thus reducing clinic productivity and profitability. You can’t offer great services if the business isn’t making a profit. As they say…”no margin, no mission”. 

Health insurance reimbursement for in-network outpatient-based physical therapy is already on the lower-end in many regions in the United States. Depending on the payer and location, reimbursement per visit can be as low as $50-70. This makes it difficult, if not impossible to stay in business seeing one patient at a time (i.e. one patient every 45-60 mins). 

Fewer appointment slots available could also mean longer wait times and delay to treatment. It’s no secret that many of the providers who operate in this model do so on an out-of-network or cash-pay basis.

Seeing Multiple Patients Simultaneously

This is the typical model for outpatient PT (booking 2-4 overlapping patients per hour) and fairly standard across the industry. There are some very obvious problems with this model in terms of care delivery, such as:

• Less individualized care to each patient (potentially overlooking details and formulating ineffective cookie-cutter treatment plans)

• Improper supervision and lack of timely adjustments to interventions

• Patient frustration and decreased satisfaction from inadequate attention

• Therapist burnout/turnover and decreased job satisfaction from high volume care 

But are there any advantages? 

Well for starters, it’s typically more affordable (arguable given increasing co-pays) and accessible for the patient. For the business, this model maximizes clinic resources and increases profitability in an in-network, fee-for-service based system. It also provides better scheduling for patients with more slot availability during peak hours. 

Another important but less appreciated benefit is the peer support and encouragement in this type of environment. Anyone who's been to a physical therapy clinic knows that many patients enjoy coming to therapy because they like exercising alongside other patients. They find the social aspect of the experience fun and motivating. This group-based environment creates a bond of solidarity between patients, therapists, and clinic staff. 

The ability to form close relationships and friendships between patients and therapists and between staff members can lead to increased job satisfaction. As I always say, one of the best predictors of whether or not a therapist will stay long-term at a company is whether they become good friends with at least one other staff member at the organization (all else being equal). 

So Which Is A Better Model?

Many would say more individualized care is better. But I would argue that whether care is individualized or group-based is of secondary importance. The primary consideration should always be whether clinical care provided is safe, effective, and financially feasible (in that order). The method of delivery is- after-the-fact. 

Just because clinical care is individualized and a patient works one-on-one with a therapist does not necessarily mean that the care rendered would have been any better or more effective than care delivered in a group setting.

All it means is that the clinician has a greater opportunity and potential to assess, receive feedback, make adjustments, and educate the patient. But without the appropriate training, clinical reasoning skills, or quality assurance, this individualized care is not necessarily better than group-based treatment, and this extra potential may be wasted. 

In fact, it could even be more problematic if the therapist is using techniques of questionable scientific evidence. You can provide someone with the best quality tools and kitchen, but if the person doesn’t know how to cook, you’re not getting a Michelin-star meal. Likewise, put Gordan Ramsey in virtually any kitchen and you’ll likely get a pretty good dinner.

The point is that it’s not just about the amount of time spent with the patient. It’s about what is actually being done in that time. A patient can spend an hour with a therapist who performs a dozen techniques and exercises, but only 1-2 of those interventions may actually be providing >80% of the result for the patient.

What Does The Research Say?

Depending on the study you review, each individual orthopedic condition may have different recommendations. But some of the results may surprise you. For example, group physical therapy for shoulder impingement syndrome has been shown to produce similar clinical outcomes to individualized therapy¹. Even more surprising, there is evidence that group-based physical therapy is superior to individual rehabilitation in adults following total knee replacement². 

Finding a Balance

So which is better? As always, the answer is context-dependent. Who is the patient? What condition/diagnosis do they have? What does their mobility, function, and medical history look like?..etc

There are some basic principles that are universal. First and foremost, clinics should avoid putting patients at-risk for injury. Therefore, treating multiple patients simultaneously is not recommended if one of those patients is at risk for falling, has cognitive decline, or if they have some condition that requires constant supervision. 

Even if they do not have one of these conditions, some patients need more supervision and cues to ensure appropriate technique during therapeutic exercise. These patients are better treated one-on-one. This should go without saying, but clinics need to follow the golden rule in medicine- Do No Harm.

Following “Do No Harm”, clinicians should also be aware of the medicolegal implications of treating multiple patients simultaneously. Despite it being fairly “black-and-white”, legally speaking, there are a lot of clinics that treat (and bill) Medicare patients simultaneously or use PT Aides to render physical therapy services and bill to insurance using CPT codes. We’ve all seen it.

Beyond those two points however, the answer to whether or not to use individualized therapy is largely driven by the patient's needs and the actual clinical intervention. And I can clearly see situations where patients would benefit from either treatment style so long as the interventions themselves are clinically indicated and based on sound reasoning. 

Ultimately, these types of operational decisions need careful consideration in terms of scheduling patients and billing appropriately to maximize revenue. By implication this means that a skilled manager will have to look at both clinical safety/effectiveness and make an economic analysis of individual versus group physical therapy when deciding how best to incorporate both types of treatment into the clinic.

Thanks again for reading and I wish everyone a safe and Happy Independence Day!

Resources:
1. Ryans I, Galway R, Harte A, Verghis R, Agus A, Heron N, McKane R. The Effectiveness of Individual or Group Physiotherapy in the Management of Sub-Acromial Impingement: A Randomised Controlled Trial and Health Economic Analysis. Int J Environ Res Public Health. 2020 Aug 1;17(15):5565. doi: 10.3390/ijerph17155565. PMID: 32752234; PMCID: PMC7432922.

2. Krumov J, Obretenov V, Bozov H, Tzachev N, Milanova H, Panayotov K, Papathanasiou J. Is group-based physical therapy superior to individual rehabilitation in elderly adults after total knee arthroplasty? A prospective observational study. Eur J Transl Myol. 2022 Dec 5;32(4):10984. doi: 10.4081/ejtm.2022.10984. PMID: 36533668; PMCID: PMC9830394.

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AI has been making some big waves in the musculoskeletal space this past year. First, with Sword Health confirming its status as the “largest care provider through artificial intelligence”. And most recently with the National Health Service in the UK employing Flok Health as its first ever AI-powered physio clinic to help the overburdened universal health system reduce its 3+ month wait list for physical therapy visits. This raises a lot of questions about how AI will affect the future of conservative management of musculoskeletal care. 

• Will patients prefer to engage with artificial intelligence? Or will they miss the “human touch”? 

• Can AI provide equal (or better) care compared to the average Doctoral-trained physical therapist? 

• Will clinics be able to outsource and bill for services performed by AI? 

• What about the regulatory aspect? What will happen if there is a problem that requires legal action? Who is responsible? 

• Will AI put physical therapists out of business? How will this affect the market dynamics? 

• In general, is this good or bad news for clinicians? Managers? Patients? 

Flok Health

Given the long wait lines (apparently more than 300,000 citizens on a waitlist) and the high demands for conservative musculoskeletal care, it’s easy to see why the NHS was incentivized to be among the first to roll out a completely autonomous AI solution. Instead of waiting months for a physical therapy appointment, Flok Health provides UK citizens with same-day video appointments with an “AI physiotherapist”. Flok is the first technology to be granted regulatory clearance for automating the triage, assessment, and treatment of back pain (the only condition that it will treat for the time being).

Patients can access the AI Physio via a smartphone app.The AI program uses a clinical decision engine to provide treatment recommendations based on the latest clinical evidence. The aim is to offer UK patients the option to choose treatment from an AI physio immediately instead of waiting 3 months for an appointment. Even if a modest percentage agree to it, it will help those seeking conservative care to get access immediately, while simultaneously shortening the wait time for those who need in-person care. 

Did they achieve the goal?

In short, the answer is yes...at least according to Cambridge University Hospital trial data, which demonstrated not only that the technology helped reduce wait times for physical therapy, but when they ceased using the AI at the conclusion of the experiment, the waitlist for in-person appointments increased by 50%.

So How Does Flok Health Work?

One of the issues with physical therapy is that it is incredibly labor-intensive. This is even more true for PT compared to other healthcare services given that time spent with a physical therapist can range from 20-60 minutes and recurs multiple times per week in many cases. And the need for continuous follow-up with a highly educated professional makes it even more difficult to deliver this type of care at the scale needed in most health systems. Thus, Flok Health is able to create immediate access to a service that is typically gated by a human resource component. 

Using a video assessment from the app, the AI physical therapist provides an evaluation of the patient's symptoms, determines if the patient is appropriate for AI treatment, and then prescribes exercises and pain management techniques over weekly, 30-minute structured “video calls”, adjusting the treatment based on the patient's progress, as well as subjective information provided to the AI. The prescribed techniques are unique to each patient profile and selected based on the patient’s individual symptoms and movement assessment. 

What About The “Patient Experience”?

Flok’s AI uses patient reported outcome measures to test how well the system works in producing a clinical improvement based on its intervention, as well as measuring the patient’s confidence in self-managing their condition. And according to an NHS survey of those patients receiving care from an AI physical therapist, all respondents reported their experience with Flok had been at least equal to seeing a human physical therapist, and 57% of patients said they thought the AI experience was actually better. Is this hard to believe?

Flok Health makes it easy for the patient. Once the patient opts for the digital pathway instead of waiting to see an in-person therapist, they are registered and onboarded to Flok’s system. The first visit is a triage assessment. This is a structured video visit where the patient answers  questions, and depending on their answers, the AI will respond accordingly, modifying its line of questioning.

Under the Hood

The technology itself consists of two components. The first component is an AI decision engine, which chooses what should happen next to the patient. The second involves a system which assembles and streams video to communicate the decision with the patient. This is the avatar of the AI therapist presented to the patient.

The AI physical therapist is actually a real person who was recorded in a professional studio. However, this second software component will pull specific sequences apart and reassemble a series of frames in a unique order based on the specific interaction it has with each patient. This unique blend is necessary because the decision-making core is just one piece of the puzzle, while presenting that information to the patient is also equally important. 

There are other tools on the market that allow for the question-and-answer format via text-based interaction. However, Flok Health’s decision to use a video-based technology creates a much more engaging experience for the patient and allows for communicating nuance and clarity in a manner that is difficult to achieve with a simpler text-based platform. 

For the system to work, it has to interact with the patient in a way that the patient can relate to, while simultaneously affording that clinical subtlety that occurs during a hands-on physical therapy assessment. This is one of the reasons Flok has chosen to use a video-based format. It’s not enough that the software chooses the correct course of clinical action, it also has to make the patient feel as though they are receiving that information and having an experience with a real human. 

Of note, the system isn’t simply playing a recorded playlist of videos. Instead the system is stitching together video frames in unique sequences in real-time based on the patient’s response. This differentiates Flok’s AI from other software available which uses a static decision-tree for digital triage, which is useful but not quite sophisticated enough to cover every scenario, nuance, and range of clinical pathways that we see in an evidence-based physical therapy encounter. 

Is It Safe And Effective?

Flok determines whether a patient is appropriate for their service, and if not, the technology will refer to in-person physical therapy or an appointment with a physician. Their triage process has undergone testing, and (so far), there have been no reports of missed red flags in their assessment. The AI will also flag to the clinical team if it is unsure if the patient is an appropriate candidate.

Whether a condition responds well to conservative care is difficult to measure. In part this is due to the heterogeneous nature of physical therapy as a discipline. What constitutes “physical therapy” is largely determined by how the therapist assesses and which interventions they choose. This will vary greatly between therapists. Patients tend to see physical therapy as a commodity, believing that each organization and each provider is offering the same service. But the service (and the outcome) will vary greatly between providers even in the same organization.

Even worse, most clinicians and organizations do not quantify their clinical outcomes or provide any level of quality assurance that is meaningful. So you have a recipe where each clinician is doing something different, and of the interventions they are doing, they are not typically collecting and analyzing data on the outcomes. And those that do collect data very rarely go back and review this data to make interventional changes in real-time or after the fact so as to modify their clinical practice over time.

But it gets even worse. Most human physical therapists aren’t even using evidence-based recommendations. A 2019 systematic review conducted by Zadro and Ferreira found that more physical therapists today are providing treatments of unknown value in this decade compared to the two previous decades.

Indeed, I’ve walked into many clinics where the so-called medically necessary physical therapy intervention rendered was nothing short of a series of exercises that a patient could find on YouTube if they wanted (combined with a 10 minute massage to “get those knots out”). In this sense, Healthtech companies could easily replicate and provide these cookie-cutter, glorified personal training sessions that are done in many clinical settings and outsource a large portion of physical therapy visits. But this isn’t because the software is necessarily better than the human. It is simply replicating the same non-skilled intervention that the therapist is doing.  

A sophisticated AI system, however, could in theory follow the latest clinical practice guidelines and recommendations, and will do so consistently for every patient seen so long as it is programmed with that knowledge in its decision-making engine. So over time, I predict that we will eventually reach a point where an autonomous AI physical therapist is indeed more skilled and more consistent than a human counterpart.

Do Patients Really Want To Work With A Machine Instead Of A Human?

On face value, you might think the answer is an emphatic ‘no’. I would have thought the same. Until I saw this video of Sundar Pichai demonstrating Google’s AI assistant calling a restaurant and making a reservation, and doing so with a level of sophistication such that the person answering the phone was not aware that they were speaking with a machine. Have a look:

…and this was 6 years ago! As the technology develops, I have no doubt that users will eventually be unable to tell humans and AI apart, except for the fact that AI will undoubtedly be more reliable, readily available, and far more consistent. It’s not hard to imagine a time when someone will prefer to get on the phone with an AI program that will listen to their concerns and respond in an empathetic manner, while answering all of their questions and concerns.

This type of thought may seem far-fetched, until you step back and look at the cultural shift that is taking place in our society where more and more of us humans are interacting with autonomous software systems. 

Think about this for a second. How often do you ask a virtual assistant like Amazon’s Alexa for an answer to a question? Or to set a timer? Companies like Tesla are working steadily towards developing fully autonomous vehicles on the road. Many organizations are using chatbots and customer service platforms to handle customer inquiries and provide support. In the financial world, AI systems monitor and analyze transactions in real-time to detect and prevent fraudulent activities. Streaming services like Netflix and Spotify use AI algorithms to suggest content based on user preferences and viewing/listening history.

In healthcare, surgeons can now use autonomous surgical robots such as the Da Vinci Surgical System to assist in performing operations. It’s not difficult to see that a time will come where AI will be part of the mainstream zeitgeist. The Overton Window is literally moving in real-time and this will affect musculoskeletal care in a big way! 

The heterogeneity in MSK practice patterns is astounding. It is quite difficult and takes an extraordinary amount of time to adopt musculoskeletal clinical guidelines and evidence-based practices at scale and applied consistently in a traditional clinical environment because doing so would require behavior change across thousands of clinicians. Autonomous systems can take newly published clinical practice guidelines and implement them immediately and consistently across a population and analyze the effectiveness. And it can be implemented far quicker than would be the case in a traditional clinical care model.

What About The “Black Box” Phenomenon?

The so-called “Black Box Phenomenon” refers to the well-known issue of transparency, clarity, and interpretability when it comes to the internal workings of an AI system and its decision-making process. In other words, the model's internal processes are opaque, thus clinicians (and even developers) cannot easily see or understand how inputs are transformed into outputs. This is often due to how advanced these systems are, especially the deep neural networks, which involve numerous layers and parameters, making it difficult to trace the specific pathways that lead to a particular decision or prediction.

This creates a trust issue. If clinicians do not understand how the AI system is choosing a decision, how can a health system trust the AI, particularly in high-stakes medical situations, where the consequences of a wrong decision could be harmful to the patient?

Flock Health avoids the black-box phenomenon through a language-based approach which makes the system predictable and observable with a system that can be audited with full access to every encounter, transcripts of conversations, records of clinical decisions and why those decisions were made. 

Flok Health Isn’t The Only Player In The Game

Meanwhile, Sword Health has already delivered in excess of 1 million sessions of AI-based physical therapy care in the previous year. In Sword’s hybrid approach, the human therapist oversees the patient’s progress while the AI care specialist, Phoenix, is available 24/7 to guide patients through their individual sessions suggesting modifications and form correction through their motion sensor technology. In this way, Phoenix functions almost as a physical therapist assistant. Like other AI programs, Phoenix can interact directly with patients, asking them about their symptoms and how they feel while performing each exercise, and respond accordingly,  thus providing for a more “human” experience. Moreover, Phoenix will gather data, provide insights, and suggestions that it gleans from these treatment sessions to the supervising human physical therapist.

Will AI Replace Human Physical Therapists?

AI is highly unlikely to replace traditional physical therapy as a whole, at least not at this point in time. However, it can be a great tool as an extension and adjunct to in-person physical therapy, especially for those diagnoses that are simple, straight-forward, and do not require intensive hands-on care. It will also temper the burden for many patients that are unnecessarily gated by availability of physical therapists and costs of attending frequent sessions. It is not possible (at least not yet) for AI to cover the full range of patient conditions and populations (neurological, post-operative, pediatric,...etc) that exist to deliver care to the population. But it can take common orthopedic issues with relatively simple and routine clinical encounters off the board for a large swath of the population.

I do not believe physical therapists will have to worry about being replaced, especially as the demand for their services greatly outpaces the number of therapists on the market. Perhaps this will decrease the number of those 4-6 patient-per-hour “PT mills” that still exist. However, one thing is certain- therapists will have to up their game as a whole. 

We need fewer interventions of questionable evidence and/or curative value and more treatment that is based on clinical reasoning, high quality research, and subclassifications which lead to outcomes that can be standardized and quality-assured.  This is especially true for very common conditions such as low back pain and knee osteoarthritis that affect large portions of the population, where clinical evidence is largely in favor of conservative care, and where these types of scalable clinical applications expedite care delivery care delivery to patients without the cost and human resource constraint associated with standard physical therapy.

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In our field of musculoskeletal care, maximizing organizational success requires a nuanced understanding of both leadership and management. Though often used interchangeably, these terms represent distinct concepts, each vital for achieving excellence in healthcare delivery.

And what I find is that most organizations lack one of the two (or both). And it isn’t always apparent or self-evident how this impacts the company, but suffice to say, a lot of internal friction, financial difficulties, and poor clinical results could be avoided if companies in our space operated with both effective leaders AND reliable managers. 

The confusion between leadership and management is common but its significance goes beyond just organizational hierarchy. Many equate "leaders" with top-level executives and "managers" with mid-level supervisors, but this view is misleading and oversimplified. Leadership and management are not hierarchical but complementary roles necessary at all levels of a healthcare organization.

Understanding Leadership and Management

Leadership in MSK is about making a significant positive impact by uniting clinicians and supporting staff around a common goal: improving patient function, mobility, and quality of life. It involves envisioning the future, identifying opportunities, and becoming an agent of change. It’s not about being a charismatic person (or “rizz” as the kids say these days); it's about specific behaviors that inspire, mobilize, and bring others in touch with their own resources. Leadership can be found at all levels of the organization, although it is most pressing at the level of senior management. 

Management, on the other hand, involves the systematic processes essential for day-to-day operations in a musculoskeletal care setting. This includes scheduling and staffing, budgeting, quality assurance, and marketing. Effective management ensures that the clinic consistently produces quality and accessible services within budget.

Effective management maintains stability and efficiency so that every patient’s treatment plan is executed flawlessly and the organization runs smoothly. This is a challenging but crucial task distinct from the visionary and change-oriented nature of leadership.

Balancing Leadership and Management

In musculoskeletal care, the roles of leadership and management must be balanced to ensure both stability and innovation. Managers focus on short-term goals, such as ensuring the clinic meets its productivity targets and maintains high standards of care. Leaders, however, look at long-term visions, such as integrating new rehabilitation technologies, incorporating innovative payment models, or expanding services to address emerging patient needs and open new revenue streams.

Leadership Styles and Situational Adaptation

Leadership in musculoskeletal care must be adaptable, employing different styles to suit varying situations. Daniel Goleman, and other geniuses in this space, often employ frameworks of leadership styles that offer valuable insights here:

• Coercive or Authoritative style: Useful in urgent situations or when dealing with new employees who need clear guidance on the clinic’s protocols and patient care standards 

• Participative or Democratic style: Effective with experienced physical therapists, orthopedic surgeons and other staff, in order to involve them in the decision-making process, foster ownership and initiative, and build buy-in through collaboration and consensus. For example, when making changes to documentation systems or developing new rehabilitation programs, gathering input from seasoned staff members ensures the program is comprehensive and operationally feasible. 

• Pace-setting or Delegative: Appropriate for highly competent and motivated employees in situations where senior staff members are involved, and have autonomy to lead certain initiatives. This can be highly effective, for example, when allowing a senior physical therapist or clinic director to oversee the onboarding, training, and mentoring of a new staff member. 

Often, a combination of styles is necessary. For example, you might initially use an authoritative approach to establish a new policy, then switch to a democratic style to gather team input to operationalize that policy into clear clinical guidelines, and finally, you delegate specific tasks to competent staff members in order to implement change.

Leadership Through Disruption

Disruption, whether from technological advancements, regulatory changes, internal crises, or global events like the COVID-19 pandemic, demands a special kind of leadership because during these black swan events, leadership which embraces change can transform potential setbacks into advancements and opportunities. For instance, the pandemic accelerated the adoption of telehealth in musculoskeletal care, allowing for remote consultations and therapy sessions, which have become integral to many practices (in fact, for some organizations, it represents the entire value proposition).

Many clinics may pass up on this opportunity, deeming it operationally unfeasible. While others give a half-hearted attempt, essentially implementing their standard clinical approach overlying a digital platform. But those who do this most effectively will modify their entire treatment approach and protocols, recognizing both the inherent drawbacks and advantages of an online video-based medium, and thus re-structuring clinical assessments of strength and range of motion, for example, and subsequent matched exercise interventions in such a way so as not to denigrate the validity and reliability of these assessments when switching to a digital medium.

The last thing we want to do as a medical profession with this new opportunity in telehealth is to turn the therapy session into a glorified online personal training/exercise session. And those leaders that truly excel will not only find a way to incorporate telehealth effectively, but also create a synergy with in-person visits, thereby creating a situation where the patient has the flexibility to do some sessions at home and some sessions in the clinic, whilst simultaneously opening up new revenue streams in the form of remote therapeutic monitoring and other innovative programs.

Leaders in our field must leverage the Overton window to explore new strategic options and implement innovative practices that were previously not considered. For example, integrating AI-driven patient intake and diagnostics (such as THERAPHA) to enhance patient assessment, streamline documentation, and support clinical decision-making. Securing these small wins over time is important to build momentum towards more extensive change. 

The Key is Visionary Leadership & Organized Management

In musculoskeletal care, the synergy between strong leadership with effective management is crucial for transforming from a good practice into a great one. Understanding and balancing these roles, adapting leadership styles to fit different situations, and navigating through disruption with innovative strategies, musculoskeletal care organizations can achieve and sustain excellence. The balance here will ensure that we not only maintain high standards of patient care, but that we push the boundaries of what is possible and continue to improve our care delivery models over time. 

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One of the issues we run into in musculoskeletal care is compliance with interventions. Whether it be physical therapy, home exercise, or even post-operative instructions, we tend to see poor compliance among the general population. Patients miss visits, are not consistent with exercise routines, and do not always follow instructions correctly or at the correct frequency. This leads to poor outcomes, and sometimes, entirely avoidable escalation to more invasive procedures. 

To understand the scope of this problem, take a look at the statistics for spinal surgery. In North America, approximately 11-14% of people coming in for back pain will be escalated towards procedural care. That number should really be closer to 5%. Among other reasons, I suspect compliance with conservative interventions to be a significant contributing factor to this problem.

The compliance problem, however, is not unique to physical therapy and orthopedics. Compliance with almost anything, whether it be medications, dietary changes, or lifestyle modifications tends to vary from moderate to poor. And compliance worsens with increasing complexity. For example, you’re very likely to get a different amount of compliance when a physical therapist asks a patient to do 1-2 exercises daily, than when they ask them to do 7-10 exercises.


We Love Diagnostics

But while patients tend to be poor at compliance, they tend to be fantastic self-diagnosticians. What do I mean by that? Let’s take a patient with diabetes as an example. These patients will prick their finger and test their blood  several times daily consistently for years, but how many of them have difficulty with long-term dietary compliance? Quite a few.

There appears to be this inherent phenomenon where patients are much more consistent with testing and re-testing more so than the actual intervention and behavior modification that will fix the problem. This explains the widespread demand and sale of devices that monitor various vital signs and markers, like apple watches, continuous glucose monitors, sleep tracking applications..etc. 

Even the demand for diagnostic imaging can be explained by this phenomenon, despite the understanding and agreement in the medical community at-large that these images yield many false positives and false negatives.

Principle 1: Turn Patients into Self-Diagnosticians

So the first way to get patients to increase buy-in with conservative MSK interventions is to take advantage of this phenomenon and turn patients into self-diagnosticians. We do this by first utilizing intervention models that rely on a response-based assessment with excellent inter-tester reliability. For example, if there is a provocative movement such as a squat, a lunge, reaching overhead, or turning the neck in a certain direction, we want to use any one of these movements which reproduces the comparable or concordant sign as a test to see if the conservative intervention produces a change. Many clinicians do this already.  

One thing that’s missed by many of these online digital therapy platforms, including those that offer remote therapeutic monitoring, is the value of the concordant sign. The concordant sign is the most valuable indicator to the patient. Much more so than a numerical pain scale or a functional outcome score. The concordant sign is also an incredibly important baseline because it will help the clinician assess progress and build a relationship with the patient.

But we want to take this assessment process a step further and train the patient to  assess themselves. Doing so will allow them to monitor the status of their condition as they perform the intervention. And if patients see a continuous improvement in their symptoms as they apply the intervention strategy at home, this will increase their buy-in and they are likely to comply with clinician instructions. 

Harness the power of diagnostics (which patients love), empower them to become self-diagnosticians, and you will see compliance rise. To reiterate- as soon as possible, turn the patient into a self-diagnostician (rather than just a self-treater). 

Involve the Patient in the Decision-making: Ask For Permission

The next step to increasing compliance is to involve the patient in the decision-making process. Now I personally dislike phrases like “patient-centered care” which tend to be hollow and mean different things to different clinicians, but if we want to achieve that standard, we have to verbally get the patient’s permission and affirmation when presenting different interventions. 

Here’s a common example that happens in our clinics. Approximately 20-30% of patients coming to physical therapy for isolated knee pain usually have a spinal source of symptoms. By that I mean that patients presenting with knee pain-only, demonstrate improvement in signs and symptoms with exercise interventions targeting only the lumbar spine. This is a common phenomenon we’ve known about for decades that is now getting more attention in the research. 

For clinicians that are used to seeing this phenomenon on a daily basis, we often don’t think twice of it. But for patients, this can be an intellectual leap if they come in with complaints of isolated knee pain (and no other spinal symptoms) and a physical therapist asks them to perform lumbar extensions. 

Even if they buy in to the clinician’s explanation, the minute they get in their car and tell their spouse (or the physician that referred them), that they’re doing lumbar extensions for their knee pain (without any other knee exercise), they’re very like to get a lot of push back from outside parties that may reduce the level of compliance significantly. 

However, if a clinician explains to the patient why they’re doing the lumbar spine screen, and then asks the patient for permission that they spend the first visit (or 2 visits) thoroughly ruling out the lumbar spine, and the patient responds in the affirmative, they are more likely to be compliant down the line. 

I can not stress this enough- It is important to ask the patient for permission. It is one of the principles of motivational interviewing…. put the locus of control in the patient’s hands. If you get a patient's permission, they are less likely to provide resistance down the road.

Explain Why They Should Care

Another way to increase compliance is to explain the “why”, explain why the patient should care…and explain it clearly. If a patient understands why a clinician is choosing a particular intervention strategy and what the patient’s role is as part of that process, their degree of compliance will likely increase. 

For example, if upon assessment a clinician deems that a patient has a radiculopathy that may or may not be mechanically responsive to conservative interventions, the clinician should stress to the patient how important the subsequent 1-2 visits will be to determine whether the patient will respond to conservative management or whether there may be an opportunity for epidural steroid injections.This increases the sense of urgency and importance of the patient coming in for those follow-up sessions

Produce TANGIBLE Results

The fourth way to increase compliance is to produce texas-sized results. By that I mean that the intervention strategy should be one that produces very noticeable results for the patient. In our clinics, we typically aim for at least 20% improvement in pain scores and the minimal clinically important difference on functional outcomes scores within 2-3 visits. If the progress is too slow, we may lose them as a patient before the intervention even has a chance of working.

For patients that have structural, post-surgical, chronic pain, tissue dysfunctions, or some other non-mechanical condition where the expected time-frame and improvement is protracted, we would educate patients on this process, the expectations of improvement, and then involve them in the decision-making. “Based on the issues we discussed, we can expect on average about a 20% improvement with therapy if you come to all the visits and do everything we prescribe for you to do at home. How does 20% sound to you? Would that be worthwhile?” 

Be Likable

And finally, the fifth way to increase compliance is to be likable. Unfortunately, likability in most instances will improve compliance more than subject matter expertise. If someone likes you, they will come back for more follow-up visits. Whereas if someone doesn’t like you, it doesn’t matter if you’re a genius clinician savant- they’re unlikely to return for follow-up and they certainly won’t be compliant with instructions. 

At the end of the day, healthcare is based heavily on human-to-human interaction. I mentioned before the importance of asking for permission. There is an undeniable sales aspect to this process. I don’t mean sales in a sleazy, used-car salesman way, where we try to sell patients on interventions that have questionable curative value (no offense to used car salesmen). I mean that we have to make the clinical experience into a consultative process that the patient can relate to. Part of this is about being likable and earning the patient’s trust. 

Turn patients into self-diagnosticians, ask for permission and involve them in the decision-making process, explain the “why”, produce BIG results, and be likable. Together, these 5 keys will help clinicians achieve meaningful impact and drive improved clinical and financial outcomes for patients seeking musculoskeletal care.

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