Competitive Advantages in Physical Therapy

[The following is pure speculative garble. My thinking could be deeply flawed on various levels. I’m sure there are things related to this topic that I haven’t mentioned, thought about, or even considered. If so, then please enlighten me.]

The Affordable Care Act is forcing healthcare changes at a very noticeable rate. Patients now incur greater out-of-pocket expenses in the form of higher deductibles and copays. Localizing this patient expense to the world of physical therapy (at least here in the US) creates new and interesting dynamics. The patient has morphed into an active medical consumer voting for their provider of choice with their money. This is where familiar circles overlap yet again.

Physical therapists now compete with more than the local chiropractors, massage therapists, and athletic trainers. The rub is now within the profession itself. If you, dear PT, haven’t felt it yet, you soon will. The question you will soon have to confront will take the form of “what would make my clinic the patients’ first choice?”

An old guy who goes by the name of Warren Buffet once said, “In business, I look for economic castles protected by unbreachable moats.”

Everyone wants a castle, but what protects their cherished castles? What keeps the competition at bay? What’s your competitive advantage?

According to Pat Dorsey (from The Five Rules for Successful Stock Investing) there are five ways a company can build a sustainable competitive advantage:

1. Real Product Differentiation – via superior technology or features

In PT terms, this would translate into techniques/modalities of treatment and specialty certifications. While this would provide a unique product, the advantage is a race against time. It’s only a matter of time before the latest treatment zeitgeist saturates the neighborhood. The virality of this differentiation will be modulated by provider and patient perception, difficulty in achieving specialized certification, etc. This temporal arbitrage could provide a nice cushion for brand-building.

2. Perceived Product Differentiation – via brand or reputation

Real Product Differentiation provides the first mover with tremendous initial potential. Given the temporal nature of such an advantage, building a brand or reputation to stack the bricks of future progress in a timely fashion is of incredible importance. Given the power of perception in terms of patient outcomes, having a strong brand or reputation will be a formidable moat.

3. Driving costs down – Walmart comes to mind.

This is always a real, but weak threat in the PT business. Retaining or increasing margins via increased volumes will likely decrease job satisfaction, increase stress levels, and result in questionable decision-making resulting in negative outcomes such as burnouts or fraud.

4. Locking in customers – via high switching costs

This was a legitimate moat until a few years ago. PT clinics basked in the bright sunshine of “in-network” status with insurance companies in hopes of greater volume of patients walking in the door. This advantage is quickly (if not already) evaporating as a result of higher and higher out-of-pocket expenses. Now it’s up to the clinic to win over the healthcare consumer. It ain’t what it used to be.

Referrals from MDs/DOs was a major driver of patients into PT clinics. However, this is already changing, and the change will likely accelerate as Direct Access provides healthcare consumers with greater perception of provider choice.

Geography plays a major role here. If travelling to another location requires greater effort, then the path of least resistance will likely be followed. Patient outcomes and experience can erode this advantage.

5. Locking out competition – via high barriers to entry or high barriers to success

I do not believe Physical Therapy clinics have high barriers to entry. This might be supported by evidence of low entry costs, increasing number of new clinics even after the recent recession, and abundance of future PTs looking to start their own practices.

Barriers to success will likely depend on network effects and brand consciousness. Geography and demographics will (and already have) provide a barbelled advantage – cities or rural areas will have inherent benefits. The middle ground (suburbs) will likely turn Darwinian, with the fittest surviving. Cities, while holding high fixed costs, will also have an relatively price-insensitive population pool. Rural regions will likely continue with first-mover advantages as a limited population cannot support many new entrants.

Of course, outsized returns will attract new players into your pond. The question is how will you maintain your competitive advantage? How will you bolster your moat?

[Again, what you just read was pure speculative garble. My thinking could be deeply flawed on various levels. I’m sure there are things related to this topic that I haven’t mentioned, thought about, or even considered. If so, then please enlighten me.]

Find me on Twitter @Cinema_Air

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Interview with Dr. Sandy Hilton, PT, DPT, MS

I had the privilege to interview Dr. Sandy Hilton, DPT, MS. I’m certain you’ll pick up at least a couple pearls of wisdom from this interview. You can find her on Twitter @SandyHiltonPT and at her clinic in Chicago, Entropy Physiotherapy & Wellness. Enjoy!

What initially sparked your entry into physical therapy?

My brother was studying for a pre-med class and I stole his anatomy & physiology book. I was 12. He helped me translate the names for the muscles from the Latin and I was hooked.  What a great thing to learn things like “Under the scapula” and “The straight one on the leg bone”… it must have been a slow summer before internet and cable.  He’d quiz me on long bike rides about what muscles we were using to ride.  That might have been better than my Therapeutic Exercise class in school.

Physical therapy was the logical choice for someone who was interested in medicine, liked to be outside, didn’t want to be a surgeon and wanted to do interesting things at work.  I thought it would be challenging and fun. Add to that a desire to ‘help people do the things they love’ and I was set. I didn’t look at the pay or the lack of access to therapy. None of that meant anything to me at the time and I’d probably have done it anyway, trusting that I could change things as I went.

You’re an instructor for NOI group. Give us the backstory. How did this happen?

I was asked to be an instructor for Explain Pain after I presented a talk at the NOI 2012 conference in Adelaide Australia, it was a humonstrous honor. I love the work that David Butler and Lorimer Moseley have done around pain education and think the NOI courses and instructors are top notch.  I did start the training program with NOI-USA but I have since withdrawn from teaching for them. There’s only so many hours and while I remain honored to have been asked, I felt I didn’t have the time to do this training series justice.  It was a tough decision but for now I am confident that it was the right one. Perhaps I can be part of the Explain Pain team in the future when my private practice and advanced clinical education programs are grown up.  Around the same time I was also finishing my DPT program.

That leads to the time management question below…

Time management is critical. How do you structure your day?

Did I mention that I just finished my DPT? [Congratulations!] Compared to last year I feel like I have many extra hours.

The ideal structure to my day is this:

Wake up, stretch, go for a jog or a bike ride to work.

Work. 7 – 4

Eat yummy food for breakfast, lunch and dinner and keep room for good chocolate.

Bike home  or go for a walk after work

Hit the Jazz bar or read

Get to bed before midnight

Weekends should be for longer rides or runs and doing something interesting.

What catalyzed the inception of Entropy Physiotherapy?

Ah… well… I loved my clinic in Ann Arbor.  I sold it to a talented OT in 2010 to follow my husband again… that brought me to the outskirts of Chicago where I thought I would work for 2 years or so while he looked for a job on the Pacific Coast.
That’s not what happened. I found out he was staying in the Chicago area, so I talked the best PT out of RIC (the Rehab institute of Chicago) and convinced her to open a private practice in Chicago, focussed on applying the current pain science to pelvic health and doing rocking awesome community health and advanced PT education… all we needed was a space.

We planned the clinic and chose the name while at the World Congress on Pain (IASP) in Milan October 2012… we came back to Chicago and found a space.  I love it. We aim to create the best community clinic for pelvic health, orthopedics, pregnancy and persistent pain.  We are working to establish a network of interdisciplinary care including a dietician, counselor, MD, massage therapist, and the local businesses – all to create a brand that places Entropy Physiotherapy as the place to go when you feel you are falling apart… where you know you will learn to get back to the things you love.  (yeah… kinda cute, but really, no one should have to give up what they love – we can find a way.)

What concepts and features of pelvic rehab can be applied to other aspects of physical therapy? And life?

A great physiotherapist (Carolyn Vandyken) up in Canada coined the phrase “Internal pelvic work is Orthopedics in a cave”.  Like all single sentences, it touches the surface of a very long answer. The danger of asking a pelvic health PT that question is that it gets graphic… putting the NSFW tag on this may be a good idea?

Peeing, pooping, sex, breathing, sitting… these are things that should be pleasant!  They are basic to life and critical to the enjoyment of life.  It’s doubly sad when the basics of life are not only not pleasurable but are now painful or embarrassing.  You can’t get away from your pelvis, it comes with you everywhere… that sounds trite, but it is true.  Pelvic Health PTs the world over are specialists, that’s not ego.  We need to know all the things a spinal therapist knows plus the gut and sexual function plus neurodynamics plus a good dose of psychology and skill with manual therapy so that you aren’t uncomfortable, slow or fumbling in private parts…

What applies to the rest of therapy?  Everything.  It is important to find joy in the simple things – peeing, pooping, sex, sitting comfortably, breathing and laughing… I suppose this counts for all of life.  What I focus on in the clinic is providing hope – helping the person to find some joys in life or movement. Together we will find a way to let him/her reclaim the important bits of life. Simple and complex at the same time.  Embracing the complexity takes courage, patience, compassion and persistence.  Perhaps one view of physical therapy is that I am  a very good life coach with great manual therapy skills and a calming (but fun) demeanor.

Running a business can tax family life. How are you balancing life and work? Suggestions?

My kids are grown, now 21 and 23 and I’m single.

I did have my own clinic when the kids were in high school and I was married… I worked from 7 – 3 and was home for the post-school chaos, dinner and homework.  I think that private practice allows for individualized hours, especially in smaller clinics.  I am a fan of “Mommy Hours” and life balance.  I make sure that I get to my appointments with Ryan, the guy who cuts my hair.  I see no reason that my patients hold their PT appointments in any less regard. I’ve never had a patient complain that I was only available during regular work hours.

As for balance – find what you love and keep time for it.  Schedule it. Hold yourself to it.  Life is too long to allow poor habits and too short to wait… so go run/bike/swim/read… laugh and love – it is what makes everything worthwhile.

(perspective: Nothing taxes family life as much as the Army.  My ex and both my kids are Army… I figure no one is likely to be shooting at me, so how stressed do I need to be? Even in Chicago)

Physical therapy research is an interest of yours. Tell us about the connection between research and insurance reimbursement. I think this is something most PTs (including myself) should know more about.

That’s a great question.  Specifically for pelvic health (incontinence, post-prostatectomy, pregnancy, sexual dysfunction, transgender work) there is a perceived push from the insurance companies to deny treatment as not medically necessary.  We need more quality research regarding the benefit of PT intervention to decrease the number of visits needed to reach functional independence.  We also need research showing that the quality of life and functional outcomes lead to less payments by the insurance company.  (of course, if studies are conducted and my theory is false – and PT doesn’t really make a difference, we must accept that and change!)

Right now there are insurance companies denying PT visits for bowel dysfunctions, bladder dysfunctions and sexual dysfunctions due to their interpretation that Physical Therapy is not needed, or that there is insufficient proof that intervention will alter outcome.  I think more participation in outcome studies such as available through FOTO will help shape the future of insurance reimbursement.  I care about this for the profession as a whole, even through my clinic is out of network for all but Medicare and Tricare.

What hobbies or extra-professional interests have impacted you as a PT? And how?

Reading is a hobby. I love to read books from poetry to anatomy and all things in between. I think the literary background (my dad was a publisher) helped me in school and helps me now.

I don’t consider myself an athlete, but I grew up spending most my time out riding my bike or climbing things. The joy in movement persists and I practice what I preach to my patients – move, do something you love for at least 30 minutes a day.

My latest hobby is stand-up comedy. I don’t think that would be a shock to any patient of mine.

I think all of these things combine to a love of learning and a joy in the complex and individual story of each person that I see in the clinic.  I love the stories and the conversations.  I could see 40 patients in a week all with “back pain” and be thrilled with the unique variations of each of them. I won’t ever get bored.

Stand-up Comedy? Performing or watching?  

Performing and writing.  I have a group of friends I do this with, and we do an email joke of the day – some of them are perfectly horrible. (the jokes, not the friends)

I’ve not gone onstage since the fall, but I’ll be back.

What big ideas/simple ideas/basic concepts do you believe will help all Physical Therapists become better/smarter/wiser?

I think we need to employ some “simple” ideas.

Learn to be critical thinkers.

Learn to separate the idea from the person that has the idea, and to not be afraid to gently discuss errors in thinking – we all have them.  There is much biologically unsound medicine… things that appear to help but are likely not helping by the way they are explained (homeopathy, acupuncture, ultrasound…. specific manual therapy techniques)… I think we need to be the most efficient providers instead of the most complacent providers.

Learn who the researchers are in your area and collaborate with them.  Learn to ask answerable clinical questions and challenge your practice patterns.

Grow.

Evolve… We have a great profession, we are exercise, movement, education and independence all in one place.  We need to be excited and consistent in teaching the public about how PT can be getting them and  keeping them  healthy.

You’ve just traveled back in time to when you were 20 years old, and are sitting face-to-face with yourself. What advice would you give yourself?

Be bold and take chances. You will need to be persistent to get what you want, do it with grace and kindness, but do it.

And publish your masters thesis, because you were right.

Favorite books and/or authors? Recommended readings?

I love science fantasy best of all.  David Eddings is my favorite author.

For PT readings?  The complete works of Professor Moseley (most are on bodyinmind.org), Dr. Mick Thacker, Dr. Dean Tripp, Dr. Melissa Farmer and Dr. Kari Bø.  That ranges from pain science, neuroimmunology, psychology and into pelvic pain and incontinence.
I’ve lately started reading scientists like I’ve studied artists and am looking at the complete works in chronological order to follow their train of thought.

What is your vision of (and for) Physical Therapy? How can we make it happen?

I would like to see Physical Therapy in the United States follow the model that has already been in place in the US Military for Physical Therapists.  In the Military system physical therapy is a point of entry.  Real, unrestricted direct access.

I think we are best situated as primary points of access for triage and referral in the case of musculoskeletal injury and pain.  There needs to be good collaboration and respect for the level of education that we have, and for the limitations to our training.  I can speak from a pelvic health perspective in that there needs to be good collaboration with MDs for pathology screening.  Physical therapists are movement and pain specialists.  We are the best of movement, exercise, strengthening, conditioning… we can be the one-stop habilitation center and the community “how to stay healthy” center as well as the first stop for rehabilitation after injury.  We offer hope, based on good science and common sense.

Describe your weekday breakfast.

Coffee (with real cream) and fruit. On a luxurious day there might even be yogurt.

Life is an adventure. Describe one of your most memorable adventures so far.

I was invited to speak at the 2012 NOI Conference.  It was held in Adelaide Australia so of course I took an entire month off of work to go explore part of a country I’ve never been to before.  I got to go on the Barrier Reef, take a Zodiak boat around Tasman Island (and see two gigantic Tuna balls!), drive the Great Ocean Road and spend some amazing days on Kangaroo Island.  Seeing the raw beauty of Australia was a “coming out” journey. Reclaiming professional and personal courage to move towards my goals that had been put on hold while I raised my kids.

Color me jealous! Let’s move on. You’ve graced the field for a few years. Give us your overview of the variety of themes (and fads) that weaved through the world of Physical Therapy since your graduation.

That is a very kind way of saying “you are old, tell me what you’ve seen”.

I gave this some thought….

1980s – manual therapy (joint mobilization at grade 4 and grade 5), NDT and PNF – i was great at all of them – you want the knee to move to 120* I can do that, just take a deep breath and relax.    I feel like I should go back and apologize to all of those patients that I hurt in order to get range.  I know now that I can get them there without causing pain. Sorry.

1990s – The era of managed care. “Get your patient better in 6 visits” and overutilization of aides, PTAs and exercise physiologists in PT clinics in order to see more patients to make up for decreasing reimbursements.  This is also when I started to hurt – wore wrist braces nightly to allow me to practice the next day… and sought out manual therapy techniques that were easier on my hands.  I found CST and MFR then, and didn’t care that the theory underpinning the technique was biologically implausible, my hands/wrists didn’t hurt and that was good enough. (I learned a lot of great manual skills but have my own words for “how” manual therapy works and what might be happening)

2001 – I came back from Germany to find that Managed Care was everywhere and someone changed the Oswestry to remove the sex question (yes, that still bothers me Julie Fritz) I also found that NDT was replaced by a more motor control theory, and there was these guys from Australia who wrote a pretty cool book called “Explain Pain” that filled in the holes in many manual therapy techniques about why people hurt.  I read as much of the work of Moseley as I could and started looking for better classes.  Ironically, I found out that one of the best pain scientists, Herta Flor, was in Heidelberg Germany, where I had lived for 3 years with such slow internet that I didn’t do any research! So close!

Meanwhile, the frustration of patients that aren’t getting better led more PTs to “alternative” treatment like CST, MFR, continued palliative care despite research saying movement has a better effect than passive treatment.  I did it too – took every MFR class i could, some Muscle Energy classes, Visceral Mobilization… Spinal Manipulation… I am a manual therapist.  But still there was something missing – a reasonable biological explanation for what was happening with the treatment.  By what mechanism do these treatments work?  Note: by this time E-stim, ultrasound and iontophoresis had enough negative results that I stopped using them in the clinic.

2010 – I got to hear Moseley in person.  And from that decided I should go to the NOI Pain Conference in England.  If there is a “turning point” in a life, that was one.  I had many good conversations that week, and it led to the papers on Pelvic Pain and a course I teach on applying pain science to pelvic pain.  That conference also led to joining the International Association for the Study of Pain and it’s conference, IASP World Congress on Pain.  If i have to chose one conference to go to I will pick that one.  I like the multidisciplinary approach and the conversations in the hallway – it’s a good one.

The future? At the risk of sounding like a groupie? Keep an eye on the people coming out of Lorimer Moseley’s program.  Luke Parkitny, Tasha Stanton and collaborators like Mick Thacker and Neil O’Connell.  Lorimer has a knack for finding great people and asking good questions. I am mostly interested in pain and what to do to prevent it/evade it/grow from it  – and I think that group will develop clever ideas.  In the mean time, people like Neil O’Connell will give those of us in the trenches some skills in critical thinking so that we won’t end up falling for the marketing or “shiny shit” in our desire to help people.  We need to keep looking for the most graceful, efficient and less wrong choices for our practice.

The Future isn’t what it used to be. What “Future-shock” events or disruptors can you imagine for the profession of Physical Therapy?

I think the changing health insurance landscape is going to shake things up in outpatient PT. It may be an unpopular opinion but I am glad for a change.  I’ve seen my share of overutilization of services, or “insurance therapy” where patients were not being treated based on their need but on the insurance benefits.  Hopefully those are outliers, but they stick in my head as something that is ultimately harmful to the patient and to the profession.

Science rocks. Let’s be bold and embrace it.

Sandy, thank you for an amazing interview! And congrats on Entropy Physio, as well as finishing your DPT. Lets do this again.

The world of Physical Therapy continues to fascinate me with the variety of passionate individuals involved. Who would you like me to interview next?

Find me on Twitter @Cinema_Air