How to Scale your PT business and Strategies for Beating Low Reimbursments with Dr. Eric Bull

Dr Eric Bull is the CEO and CoFounder of Spine and Sport, and Inc Magazine winner for 4 consecutive years as one of the fastest growing private business in the US.

In this interview you will learn:

  • How Eric scaled his practice from nothing to 7 facilities and one of Inc Magazine’s fastest growing private practices for the last 4 years.
  • How to implement statistics into your practice without seeming like big brother.
  • Eric’s strategies for beating shrinking reimbursements.

Interview Links:

Transcription:

Carl:hey everybody today we have Dr Eric Bull, Dr Eric Bull is the CEO and co-founder of spine and sport and Inc Magazine winner for 4 consecutive years, as one of the fastest-growing private businesses in the US. That’s awesome actually I didn’t even know that and I’m excited to talk with him because he’s one of the smartest and coolest guys I’ve met honestly over the hundreds of people, practice owners that I’ve survey and interviewed over the last few years so that I know he’s going to have some amazing stuff to share with us today so, Eric how is it going?

Eric:a Carl thank you very much that introduction man it was definitely very nice of you and it’s truly a pleasure getting to know you and how you’re trying to help physical therapists as well so I thank you for that from our profession.

Carl:thanks.so I met Eric, we met each other through a friend of his and we got a chance to meet in person and hang out at the combined sections meeting and did a little… That was badgering my Tesla days, we went for a little test drive it was pretty fun.

Eric:that was an awesome car by the way.

Carl:you will get one soon right?

Eric:I’ve been thinking about it.

Carl:call so tell me how you got into private practice?

Eric:actually my dad owned a chemical manufacturing plant and my mom was the director of human resources for the largest hospital system in the Midwest when I was a kid so most of the time growing up dinner time conversations were about human resources, business growth what dad had going on in the plant and so there was always this kind of entrepreneurial spirit that I think kind of flowed was in my family my grandfather was a dental surgeon who owned is owned practice my great-grandfather owned his own cigar making company and candy store.

It was a long line of having your own business being able to create jobs for other people and do well in the community that you lived. That’s the background and of course getting into physical therapy I had been and met many people that had had their own private practices and financially did well and seem to be really enjoying life and it spawned from there even when I was in grad school and physical therapy school I knew that I wanted to on my own clinic one day and just coincidentally, through the strokes and joy of life, my college roommate, a physical therapist also we wound up starting a practice about 5 years after we graduated. I had moved out west to Arizona and he’d moved east to South Carolina and we wound up catching up about 5 years later when I had returned from residency in Australia and we wound up starting a practice together in Savannah Georgia and it’s been growing ever since.

We just celebrated our 10 year anniversary February 14 of this year.[Congratulations] yeah thanks it’s one of those things that makes you feel lucky, fortunate and old.

Carl:that’s hilarious, so when you guys were getting started were you nervous at all or what kind of… Were you nervous and excited or what was… Was it a challenging leap?

Eric:there’s a lot of emotions that go into leveraging every piece of asset that you’ve ever created in a young career in order to start a practice. So there is definitely some financial anxiety, but when you’re all very purpose filled like when you really know what you are trying to do than from the very beginning we really knew who we were as a company we both have advanced specializations and certification is both through the APPA and then other specialty organizations. It was very focused on quality patient care and like that’s who we were so it was if you know who you are then there’s a market demand, America is still a great country for being able to make it happen.

So there was definitely emotions but most of them were positive.

Carl:so thinking back to when you guys were getting started I’m sure not everything went super smooth, so what were some of the challenges that you will hit in starting your practice and what were the biggest things you’ve learned that you wish someone had told you in the beginning.

Eric:there is actually a bunch of little things that I wish I would have known I definitely got a mass of scraping school of hard knocks, I had before… I started my first clinic actually 16 months after I graduated from TT school and run that for 4 years and I grew that to 2 locations that was back in Arizona and sold those for just enough money to go and do residency in Australia and came back with $11 in the bank accounts so the things that I’ve learned are, definitely always keep your eye on the finances, the unfortunate thing is sometimes people, money is a very motivating thing for criminal activity. We’ve had bits and pieces of $20 here $50 there but the more stringent that you keep your controls in it, it actually allows people to come to work and not be worried about is there going to be terminated if there is $20 missing or something like that.

Definitely providing security for your employees by keeping the documentation of money very tight and keeping written policies understood and known on that. That also protects you from lawsuits, that also protects you from the Department of Labor and litigation from employees if you terminate somebody and they didn’t actually do it sort of thing. Which fortunately has never happened but that’s because we have good policy in place if we didn’t that could have been an issue over time.

Another one would be definitely keep… Have good accounting so you know what makes you money and what doesn’t, a big one is also that I definitely didn’t learn but our first 2 clinics that we use in our current clinics is, everybody comes to work to produce a product. So that product needs to be measured, a statistic is simply one number in comparison to another but when you keep good, when people know what their products are and what they’re there to do and then you measure it with a statistic, it actually gives a really good job security and people tend to like it when it is done well.

So you know some stuff about that with your clinicmetrics.com company which is how we met, which is an awesome product as far as how can I know what’s going on in my practice, I think that over time some physical therapists and just some people in business in general think that using statistics in your business is micromanagement but it’s actually the exact opposite because somebody… If you give them a product and they can measure what they are doing and then they actually know with security if it’s continually going up or in a very high level and they keep it there… They know that what they are doing is what’s wanted and they know that they have job security so it just gives you more indicators and what’s going right.

And as far as physical therapist we certainly ask our patients objectively all the time how they’re doing, so how you doing today, what’s your pain level like or here’s this functional outcomes for… And we determine our treatment based on their responses to metrics, so I think that physical therapist in general understand that concept of managing by numbers because we do it already in the clinical practice, so having it in place for your business only makes logical sense.

And then I guess my other big recommendations or the things that I learned is, you never stop looking for good employees, there’s this historical thing where physical therapist resigns and then you really try to look for somebody and it takes you months to potentially find… Find even anybody to come into view so one thing that we changed was that we just started interviewing, we interviewed constantly no matter if we had an opening or not and when we did that we actually got really good at it we actually wound up spinning off a boutique, outpatient physical therapy private practice recruiting company called, Therapy Now because we were doing it so well.

But for our practice before we created that company in additional to our physical therapy company it was, how do we get people to be interested and constantly accessing our company.so a lot of that actually had to do with being out there being visible and really knowing who you are as a company like what differentiates you from your competitors, so that other people that like who you are can find you easily, that basically the big picture on that is never stop interviewing and looking for good help.

Those kinds of things that come to mind.

Carl:that’s awesome I got to happen ask a follow-up question there so, when you were talking about statistics you were right a lot of people feel like Big Brother when they doing it or don’t do it because they don’t want to feel like Big Brother and you said it’s motivating if it’s done right.

What are some tips on doing that right?

Eric:you know a lot of it has to do with the intention, I think that… How would I phrase that well, when you do something that is actually truly intended and you want to make it go right and you put it out there not to get all philosophical but when you put it out there in the universe that it’s going to go right it’s just more likely to do so. If you sit back and you start to speak with someone about using statistics in your practice or using metrics there can be some pushback because some people just don’t actually want to be looked at.

So explain that whole concept that it’s actually for the greater good, that it will give better job stability, there is actually this really interesting survey that… It was published in some human resources periodic and it was, what are the things that make the average employee dissatisfied and the overwhelming result was, people don’t know what’s actually expected of them at their job.

So if you can clearly communicate and most ideally have it written down so that it it’s exactly there on the exact thing that you want produced and then you find a statistic to measure that, when the person goes and gets a ton of it and then you have a statistic that accurately reflects that product, the person can actually come to you and say, hey man look I’m doing a great job like I should be immune from your raft or whatever.

But an individual produces a product or multiple products so when the intention is for you to give them autonomy by giving them the product and have it be measured the intention is truly a good one. If you go with it maliciously I think that my opinion is sometimes individuals put a statistic in because they are trying to handle a particular person that they already know that the problem is actually happening and they’re looking for a solution because the not actually going and actually confronting and handling the problem so they use statistics to try to make their point and in that case you haven’t handled it to begin with your looking for a solution you try to put the statistics in and it doesn’t go well or you back off because the person who is creating the problems or running the scissors actually hasn’t been handled well.

As a human being they haven’t been handled by the manager over the area well and statistics aren’t really like a good answer if you’re trying to use it like that, handle the person first then for your business to have the security of managing it well put the statistics in and do it because you have found out that it’s the right thing to do.

Carl:right that’s really smart, so thanks for that. I often talked to a lot of people that have started a practice and are ambitious and really want to scale it and grow, what advice do you have to people like that?

Eric:if you want to grow your practice I think you have to have is staff and a clear idea of who you are. Typically most PT practices start with the dude or the dudet and you are rocking it you got a front desk maybe you have an aide or tech, you’ve got somebody there to help do the linen and keep the clinic flowing. And then it grows and maybe you hire somebody to help build and then you start looking for a PT’s and so the thing that you have that makes life easier to have when you want to grow is to find the right people to be a new team.

So that requires interviewing so sometimes you strike it really lucky and you find the right person first, sometimes you’ve got to interview 30 people but it’s your constantly looking sometimes you just find the diamond in the rough and man it’s like I don’t have a job right now but I’ve got to get that person aboard because I could pull over here and there going to like killing the matter what they do and the better you do at finding that person whether it be an administrative staff person or a technical staff PT, PTA or any of the therapies and you’re better identifying those people to come and be on your team just the better you’ll do long-term, like more power your group will have and then the other thing is really deciding who you are as a company, I think that… Something that I’ve personally gone through is we really knew who we were, we got big really fast and then the money starts to be there and so you kind of take your eye off the prize a little bit.

You start to get a bit more freedoms in life and your purpose that you started with can become watered down, right it’s not being filtered down into the practice of much so when you have like an excellent purpose which is… Most physical therapists are typically well physical therapists as a profession were in the top 5 highest, job satisfaction in the last Eric: years according to US News and world reports and it’s because we get to help people every day and it’s just like super rewarding so how whatever you done as a private practice owner to differentiate yourself… What is it that you exactly do, what is your purpose in having your practice because there is probably other people that would like to really share in a practice that’s really motivated to help people but everybody is slightly different, everybody does it for a different reason so really knowing what that is so that all staff are on the same page because the more deluded things go it’s just like a river, the wider it is the slower it goes and you take all that water and you compress the size and it’s just full steam ahead and blazing forward.

So the moral purpose and the more intention you put on it going forward the better… Just the better is going to do, if everybody in your practice was on the same page you could walk up to any employee… If you had 50 employees and you say, what is it that you do here and they go without any lag, and they just go yeah I’m here to boom, boom, boom and they give it to you straight and they go, hey what is the goal of our business and they go, I’m here today to really kill and help as many in our community is possible and everybody was able to not only say but believe it because they saw it in the actions that were taken every day, the group would just be more powerful, everybody would be moving in the same direction forward.

So those are the 2 things I think help hired therapists which the funny thing is the recruiting company that we created actually asked those questions of the business owners.

Like why are you… What’s different about you? Because this places in the US that have difficulty recruiting, is the reality that people don’t know what separates them and it takes actually been in communication to figure out how you are different and how that could be marketed or advertised effectively to get people to reach for your practice.

Carl:what’s that company called again?

Eric:Therapy Now.

Carl:Therapy Now cool awesome, so 10 years ago when you started your practice a lot was different and I think a lot has changed since then so how as the environment changed for PTs since you got started? You don’t have to go too detail into it because I know that’s like a giant question but…

Eric:there is a, let’s see… The environment has definitely changed, I mean the pay has certainly significantly increased for your average staff PT, while the same time reimbursements gone down significantly and that creates challenges over time. When I started there was fewer physician owned practices there was less competition so it was easier to get referrals, I guess also chiropractors had done a way better job than physical therapists in marketing who they are as spine care people so physical therapists we just haven’t done as good of a job so there’s definitely greater competition from chiropractors.

My feeling is that they used to be more backstabbing than there is today in our profession, I get the sense that people are working more together so I think that’s kind of how the environment changed.

Carl:so I’m really wondering what did you do to adapt to those changes and I guess we can go through them specifically, I mean a lot of people are really concerned about the first couple of things that you mention, pay going up and reimbursements falling. What kind of things have you done to adapt?

Eric:one thing that we have done is… The hope is that I don’t ever have to pay my PT is less than where they are at right now in fact from my personal viewpoint I want to pay them way more. It’s been said, Tim Flint said that physical therapy is the best value in healthcare and I totally believe that if you look at the outcomes that we get and how much we get paid we are a heck of a deal and so I would love to pay our PTs more but with declining reimbursement the thing that how we’ve started to change that is we have really ramped up what it is that both administrative staff and our technical and physical’s therapy staff are expected to produce so that there are expected to work longer I have some friends that, their physical therapists are averaging 50 hours a week in the clinic now just scheduled patients without any time for documentation or anything like that because that sort of takes work in their area is guys want to be paid a certain dollar amount.

Something that we done is really looked also at our fixed operational costs so the days in my mind of the 30,000 ft.² physical therapy facilities are gone, we look at the future model of physical therapy truly needing less equipment, smaller spaces because the more people, is just a numbers game but the more patients that I get into a smaller space… If I saw 300 patient visits or 200 patient visits a week in 1500 ft.² facility versus a 3000 ft.² to facility at the end of the month there’s $1500 worth of rent that I paid out without any change in revenue we’ll be looking at having smaller physical spaces, with the most equipment that can fit in that space.

We started to not have as much support staff both administratively and helping physical therapy, folding laundry, flipping sheets and stuff like that, we really cut back on those sorts of things also from the changes that have been taking place so there are happening.

So that’s definitely how we handled that… And then you had said that there was a potential… That kind of addressed more the pay, what are the other things I had said as far as an environment changed?

Carl:you mentioned falling reimbursements and pay and I guess that addresses both of those. Have you seen a positive effect from those changes?

Eric:yes we have, we’ve kept the bottom line in and we’ve been able to adapt to those changes but typically most leases are 3 or 5 years so some of those things we be looking out for quite a while and only recently have we been able to make those changes and so some of that may take time but being proactive in looking at it can be… Having a plan is a smart thing to do.

Carl:so what other challenges do you see coming in the future, do you see the challenge is coming that haven’t quite hit yet?

Eric:there’s definitely like hospitals and physician owned practices… Hospitals are starting to buy physicians back which historically and especially guys that have been in the practice for a long time, in the 70s and 80s most physicians were hospitalist then until the 70s or 80s when guys went into private practices and started breaking away from hospitals and now were in a period of reintegration again. So they’ll has to be on this tour a court trend as to where that’s happening right now so the big thing as far as challengers is there’s always in my mind going to continue to be more competition than challenges, whether it be professional practices or whether it will be from hospitals in getting the physicians.

We’ve had instances where business managers the physician refers one patient out of their system they get a personal visit from the business administrator how do you compete with that because who wants to get their chops busted by some guy because a private referral like that. The main way to help with the hospitalization, physicians going back into the hospital and the [inaudible 26.44] really just out produce and out produced would be, physicians always at the core will care that their patients get results so if you know what’s happening at the hospital or have the physician practice and you truly do a better job and then you get those results of a better job, known by those individuals you will still continue to get referrals from physicians, it might be on the down though but it will just happen and the other thing is to just really promote direct access, so there’s recent survey results that have shown that less than .1% of all physical therapy evaluations on a weekly basis in the United States are from true direct access where patients come to the physical therapy practice without actually having seen the physician.

The better that physical therapists do as a doctoring profession, the better… We should have professional skills in order to communicate with our patients effectively to let the community know that those rights exist.

There’s only a couple of States that that doesn’t exist in, [inaudible 27.57] are really good rules and there seems to be a popular misconception that most insurances don’t pay for which is not been our experience when we do insurance. The better that physical therapists do and this is a… It goes into another challenge is academia, it isn’t doing is any service in helping our physical therapists to actually be able to come out and know as part of who they are as a physical therapist that they have a professional responsibility to be promoting themselves and the business that they work for to the community.

They’re still very much a… What I personally know is an ancillary to view point of the physician and academia hasn’t really made that switched to physical therapists to come out in comparison to when chiropractors come out, most of those guys aren’t going into large group practices they going and starting solo jobs and they’re better at marketing than physical therapists so, if we’re graduating with a doctorate and I have a guy whose take on their boards and still doesn’t really know anything and can’t treat my patients great, yet the one thing I really need them to do would be to be able to effectively communicate with patients and let them know about the benefits of physical therapy so that they could go out and tell other people to come see us. So that’s a little bit of a challenge and I think academia also hasn’t done a good of a job as they could on having physical therapists know the difference of what they should be expecting with a salary, when they first… This seems to be some schools aren’t really realistic on what they should be earning so yeah.

Carl:cool, so I just wanted to shift gears for a second and talk about something that you mention to me last week which is really cool and to just ask you about it, yeah you mentioned that you are doing something awesome to treat patients with concussions can you tell is about that just a little bit?

Eric:yeah, from an outpatient orthopedic physical therapy perspective we don’t typically do as much neuro stuff but a concussion is similar to a brain injury. Some concussion patients actually have a mild brain injury which has historically been harder to diagnose and it’s because the symptoms are… Came up less then but there is a slight difference between concussion… Some concussions have mild brain injury some just have concussions but neuro PTs in hospitals have been treating brain injury for forever, ever since out profession started but it’s been in that neuro inpatient hospital arena and so outpatients and inpatient, these patients aren’t… Because they’re mild they are not being seen in the neuro inpatients facilities because they weren’t admitted so historically they are being managed by the outpatients physician, by ER by an origin care potentially by an ophthalmology list or something like that because there’s typically components of… “It might be some dizziness, it might be some social integration where they don’t like to go into large crowds any more, it might be some double vision and it might be some vertigo, it might be…There’s many symptoms of that and so what we did though is there is a neuro PT out of Canada who has developed some very… Just from her neuro side sees married to an outpatient dude so she’s been doing some really higher level training to the outpatient orthopedic guys on how to actually treat these patients in the clinic.

And so we got all of our staff trained and we are just seeing really interesting results I mean firstly it makes your physical therapist better differential diagnosticians and then there are actually getting these whiplash, when you get a whiplash patient or it could even be somebody that has had these odd symptoms but when you’re doing a good their own history like this patients is still actually having symptoms of concussion and we can use those neuro treatments in the outpatient clinic to actually get these guys reading better, less dizzy, mole coherent, thinking faster, responding faster and just feeling better so it’s a really nice mix between what we had been thinking about how we treat cervercargenic headaches, tension headaches and now we start to see these patients with really interesting histories… When you know to ask the right questions and do a much more thorough subjective and objective examination you can screen these things and actually determine if the patient is then concussed or not so it’s been really interesting we are having great success with it and the physicians are really interested in that so it’s a nice layering for what we do with our medical… Differential diagnostic medical screening from an outpatient orthopedic PT view point and adding this in it’s been really great for the guys, the guys can get on with their practice.

Carl:that’s awesome, cool so I think that this has been amazing and you shared so much great information that people are going to love so I think we can wrap it up now so do you have any parting advice for people out there, practice owners out there?

Eric:yes I think we really covered quite a bit of it don’t you, knowing who you are, how to differentiate yourself, making sure you get good results, always interview and measure what you do, make the product that you want your staff to do known and then you’ve got to measure it. So I guess the last thing on measuring it would be, it tends to be the first job of a new business owner, who is not skilled and using metrics that if the numbers go down which means that the product isn’t being done but they run over and handle it every time it goes down instead of equally rewarding when it goes up and handling it when it goes down right, so when somebody does something good and the numbers go up go and find out why.

Carl:exactly and share that, share that with everybody.

Eric:make it and you’ve got that and strengthen it don’t just go there and always be handling the negatives like there is of course the CEO joke is that they run around with fire extinguishers and just put it out but that’s only handling the products when they’re not being gotten that’s reflected in the statistics instead of actually going there when it is good and rewarding and praising when somebody is doing a good job. So that’s my last thing I think there bud.

Carl:well thank you so much, if anybody wants to contact you how can they reach you?

Eric:yes I’m happy to help anybody that I can and my personal email is my last name bulle@spinesport.org and in the subject line just put reference Carl or something like that so it doesn’t get flagged on my junk mail.

Carl:awesome thanks so much Eric.

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