How to Break Free from the Insurance-Based PT Trap

I I did open my cash based practice in 2013. So I've been in a successful cash based practice for quite some time, and it's wonderful here. But I don't forget what it was like in the insurance world. I remember it vividly. I remember the time when I was working in a pool environment, but there was one day where I walked into my office, walked into the community area and I looked at my schedule.

And I'll admit at the time, it was a paper schedule. So it was a quite a quite a long time ago. But I looked at it and all I saw were, like, tons of names scribbled all over the place. And I looked at my manager and I said, who vomited on my schedule? And he was like, what are you talking about? And I was like, it just looks like a vomit of names. I counted. I had 38 patients that day. 38 patients in one day. And I was like, how am I ever gonna do this?

And I did it. And I man, I hustled. And those patients, they got better, took some time, but it came at a big cost to everybody. So I really vividly remember what it was like in that world, and I don't blame the big companies for that. So if you think about it, unfortunately, the way the insurance world has worked out, most big companies are they're basically not getting paid what we deserve for what we're doing.

And so it's because of that that PTs are finding themselves having to see multiple there multiple patients at once. You know, the companies, they have to survive. They have overhead. They have to pay their their salaries. They have to pay our salaries.

They have to pay all the overhead expenses. So it's really not the big company's fault. I feel like what's happening is the the the compromised pay from insurance companies is really what's forcing us to have to sacrifice our standards, and that's one of the biggest issues. I feel like if you look at how the standards have trended over the years, especially from what I've seen when I graduated PT school in 2000, when you look at the standards of care, you can see PTs are so burnout. I mean, we all know it.

And we're we all got into this because we wanna help patients. But it's undeniable that when you're trying to juggle multiple patients at once and you're working long days and then you finish those days and you have to then do hours and hours of notes on top of that, it's just impossible to keep the standard up here. On top of that, those of us that want to learn more and be better at what we're doing, we'll go to continuing education and we'll say, you know what? I'm gonna learn this new tool. It's gonna fix more people.

This is what drives us. This is what thrives us. I love this. I'm gonna do more of this. We go to this course. We spend 2 days learning, and we come in all pumped and that I'm gonna get this person better. And then we go to do it and we're like, shit. I don't even have the time to retest. I don't know if I'm doing this right. I don't have the time to put this into practice.

You can't get better that way. You can't get patients better that way. So the whole process of us being overwhelmed in the working environment is not allowing us to grow as clinicians. It is stifling our progress as clinicians and it is therefore stifling our progress for our patients. So we need to get out of that.

You know, the the world of having patients babysit on machines while they do exercises, what good does that do? That makes us glorified trainers, and I have a lot of respect for personal trainers. They have an important place, but even many personal trainers are spending more 1 on 1 time watching their patients do their exercises than we are able to do in an insurance based environment. It's not productive. Furthermore, when we're looking at a patient, you know how we get them better faster?

What we learned in school, right? Assess, reassess, assess, reassess, assess, reassess. When you have 4 people and you're like, oh shoot, don't just don't hurt yourself on that machine. You don't have the time to assess, reassess, and actually find that root cause. So this is the problem.

This is what is stripping us of our reputation because it's warranted. We're not putting the time in with our patients that they deserve, that we deserve. And it's this cycle that needs to end. The reputation piece of that, we see it when we go to barbecues. You know, I go to my son's birthday party, my son's friend's birthday party, and I'm talking to a parent and they tell me, oh my God, I had a shoulder issue.

And and I think I'm I think it's just as good as it's going to get. What do you mean it's as good as it's going to get? You're 35 years old. We got to be better. You want to go rock climbing.

You should do that. People are feeling like they're not going to get any better because they've been to PT, and it's not making them better. That's our reputation at stake. We need to take control of that. So those of us that are motivated, right, we're going to go in, we're going to learn more tools, and and then we need to apply those tools.

Right? But here's the problem. Many people are actually losing their motivation to be better as therapists on top of this Because all of a sudden, I think they're losing their confidence. They're seeing patients for many, many visits and they're not making changes because they're not in an environment that can create change. But instead of recognizing the real problem isn't that they're not capable, it isn't that they're not smart enough, it isn't that those therapists don't have the right tools.

What it is is that they don't have the right environment to apply those tools and show their their show their patients and themselves that they can actually make a change. So on a whole nother level, our confidence as individual professionals is plummeting. Not a good thing. Not a good recipe for anybody. We gotta get out of this.

So this is how we're gonna do it. We're gonna open a cash based practice. Right? We're going to create an environment that allows us to have the time with our patients that we both deserve. We're going to educate ourselves in a way that we can apply those tools to make everybody better.

We're going to ask for a fee that's nominal and actually oftentimes comparable to what people are paying in co pays when they come 3 days a week to an insurance based world versus one day a week, potentially in our world. And we're gonna ask for that fee because our time is valuable and they recognize that it's gonna be valuable to them. There was an moment for me when I was teaching. And, so I started teaching dry needling in 2012. And I'd already been a clinician for 12 years, and I've been I was in the insurance, world, at that time.

I guess I really was teaching in 2011. I was training to teach. So we did we did, I think it was 5 audits under other instructors for dry needling. So I was essentially teaching in 2011, officially teaching in 2012. But during that time, those of you that use dry needling know it's a very valuable tool for test retest.

We can go in with a with a dry needle and affect a muscle that we think is involved. And right away, we we really expect to see motion changes if we're in the right area. Well, at the time, we were going through selective functional movement assessment in our in our courses every weekend. And we did that because there is a, you know, regional interdependence, The ability of certain areas of the body to affect other seemingly unrelated areas is a real thing. And so in our courses, we were going through Gray Cook's selective functional movement assessments with every section that we were teaching.

So this one day I was going to show, we did it in regions. I was gonna show how to dry needle the quads, and I did the, maybe 1 adductor, adductor longest with it as well. But we went through the full selective functional movement assessment in the small breakout. And so the the therapist that I was gonna be my patient on on this course, he, I took him through. His neck range of motion was atrocious.

Like, active range was, like, 20 degrees both sides. It was so bad, and extension was horrible too. And he felt it. I was like, what's going on there? Alright. I just made a comment like that. Didn't expect anything big. Saw some other things, but that was the biggest limitation in him. Put him on the table, taught the dry needling approaches for the quad and adductor, and all of a sudden this guy stood up and I was, like, well, let's go through it all. Neck range of motion, restored.

Fully restored. I was like, okay. Well, there's a very big confirmation that regional independence is a real thing. I need to pursue this further, and I need to pursue this with all my patients. So I go back to the insurance based practice that I was in.

Again, not judging the people that I was with at the time. They're all doing the best they can in terms of our my leadership there. But I'm trying to apply this, and I'm still stuck. I was still stuck with, like, how can I test, retest? And and I was doing the best I can, but I knew that if I had more time with my patients, I could actually make a bigger difference.

So that's how this cash based model for me came out. And that's why I'm urging you to recognize that we need to get out of this insurance based model if we really wanna make a difference in patients' lives. And secondly, it's doable. Like, there are it is a completely manageable thing. And if you continue to work with us, we're going to help you find some tools to do it.

So getting back to our original point, how is opening a cash based practice going to solve this problem of insurance companies stripping us of our reputation, damaging our brand and hurting our own self confidence as individual professionals. The way our cash based practice model is going to help us with this is number 1, it's going to give us an environment that allows us to test retest and get to the root of the problem better and faster. Right? We're going to get patients better faster. That's why we all got into this in the first place.

The second thing that CAS based practice model is gonna allow us to do is we're gonna be able to clean up form cues with exercises like that. So rather than missing the boat when our patients on the other side of the room and we have 3 other people we're managing and we don't see that their knee is going to valgus or we don't see that they're squatting when they should be hip hinging or we don't see that their foot is falling into pronation or we don't see that they're not pressing down through their big toe. When we miss all those things, we miss opportunities to help them get to here and they need to be here and we want them to be here. So we got to get those tools and the cast based practice model, 1 on 1 physical therapy. That's the way to do it.

And the last piece of this is that from a mindset perspective, we're going to help our patients from a mindset perspective. And what I mean by that is when patients have 1 on 1 attention like they get in a cash based practice model, they're heard, they're seen, and their issues are addressed. That's so important because when they're heard and they're seen and they know that their issues are being addressed, they have buy in. And by that, I mean, when you say to them, you know what? This, this, and this is occurring, and I need you to do these 2 exercises.

And when you do these 2 exercises, you're gonna feel better. Even better than that, you can show them on the spot because you have time. Oftentimes, if I want them to do an exercise, manuals first. I'll do the exercise and show them test, retest. I'll say, here's how you move. Do you feel how you move? Yes. I do. They feel how they move. They feel that when they row rotate They feel how they move.

They feel that when they row rotate to the left, their hips don't go with them. Now I say, let's do this exercise. We might do 5, 10 reps. That's enough to get recruitment changes if if it's appropriate. Then I retest them. They're like, oh my god. I can move to the left better. That's the buy in. You have time to give them the buy in. They're going to put the work in.

They're going to get better. So the mindset really matters. And in the cash based practice model, you're going to be able to fix that. You're going to save our reputation. You're going to save our brand. You're going to save our patience. Everybody's going to get better faster. Let's do it. So in the end, what happens is patients again respect our work, we respect ourselves, and everyone gets better faster. It's a win win win.

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